Pennsylvania Department of Health
 EMBASSY OF HEARTHSIDE
Patient Care Inspection Results

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EMBASSY OF HEARTHSIDE
Inspection Results For:

There are  248 surveys for this facility. Please select a date to view the survey results.

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EMBASSY OF HEARTHSIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, Civil Rights Compliance Survey, and an Abbreviated Survey to investigate eight Complaints, completed on February 20, 2026, it was determined that Embassy of Hearthside was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.
 Plan of Correction:


483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.
Observations: Based on staff interview, it was determined that the facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. Findings include: During an Interview with Employee 9, dietary aide, on February 17, 2026, at 9:25 AM, she revealed that the facility currently did not have a dietary supervisor or a certified dietary manager (CDM) employed. Interview with the Nursing Home Administrator on February 18, 2026, at 2:15 PM confirmed the facility did not employ a full-time registered dietitian or qualified director of food and nutrition services. Cross Refer 801 and 804 Qualified dietary staff Previously cited 3/14/25 28 Pa. Code 201.18(b)(1)(3) Management
 Plan of Correction - To be completed: 04/21/2026

The facility continues to advertise for a dietary supervisor and a certified dietary manager as well as a consulting dietitian. Regional Dietary Manager continues to provide oversite until qualified dietary manager can be hired.
Education has been provided to administrative staff by Regional Dietary manger on guidelines to meet regulations for qualified dietary staff.
Ongoing recruiting continues for placement of qualified dietary manager. Recruitment efforts continue to be reviewed until qualified dietary manager hired.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations: Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and two of four nursing units (Nittany and University). Findings include: An observation in the facility's main kitchen on February 17, 2026, at 9:25 AM with Employee 9, dietary aide, revealed the following: The dishwasher room ceiling tiles above the clean dish line have yellow water damage and are buckled, broken, and hanging down revealing broken drywall beneath the ceiling tiles. A dirty vent in the same area is uncovered and dust and cobwebs are visible inside. The drain in the center of the dishwasher room has water pooling around it and white 2 half inch sized pieces of grout from the floor are in the water around the drain. The three-compartment sink has a continual drip of water from the handle of the hot water faucet. The knobs of the stove have large amounts of dust and debris collected behind and between the knobs. Both ovens are noted to have brown residue built up inside the glass doors and inside the ovens. Expired apple cider vinegar on the spice shelf was noted to have a best before date of August 5, 2025. The refrigerator was noted to have multiple containers of food dated February 16, 2026, that were leftovers from the previous day, however no cool down temperature logs were available. Employee 9 confirmed that there was no binder that contained any cool down log information in the kitchen. A storage shelving unit of clean kitchen equipment had a plastic cover on the shelf that was broken and left a two-inch exposed area in the middle of the bottom shelf. There is a half inch deep triangular shaped hole in the floor in front of the tray line caused by a broken floor tile. The refrigerator was noted to have four quarts of expired Lactaid milk, dated February 15, 2026. Observation of the nourishment room on Nittany unit revealed a zip lock bag filled with condiments including mayonnaise, ketchup, and mustard. There was no date on the bag to indicate when the bag was delivered or a best before date, and no items within the bag were noted with any expiration or best before dates. Employee 11, licensed practical nurse, confirmed that these items are delivered from dietary. The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:45 PM. Chapter 8 of the 2018 International Plumbing Code, 802.3.1 Air gap, stipulates that the air gap between the indirect waste pipe and the flood level rim of the waste receptor shall not be less than twice the effective opening of the indirect waste pipe. Chapter 8 of the 2018 International Plumbing Code, 802.3.2 Air break, stipulates that an air break shall be provided between the indirect waste pipe and the trap seal of the waste receptor. Observation of the University nursing unit ice machine, with Employee 6 (licensed practical nurse), on February 18, 2026, at 10:56 AM revealed that the white drainage pipe from the back of the machine had no visible air gap between the indirect waste pipe and the floor drain. Employee 6 stated that this ice machine is the only ice supply for all residents on the second floor of the facility. The surveyor reviewed the above ice machine concerns during an interview with the Nursing Home Administrator and the Director of Nursing on February 18, 2026, at 2:00 PM. Cross Refer 801 483.60(i)(2) Store, prepare, food safe and sanitary Previously cited 3/14/25, 5/6/25, and 8/25/25 28 Pa. Code 201.14 (a) Responsibility of Licensee
 Plan of Correction - To be completed: 04/21/2026

The regional maintenance director has conducted his full and complete evaluation of the kitchen physical area on 3/5/2026 and has reviewed needed materials needed for repairs.
Maintenance, in conjunction with the regional maintenance director and Administrator, will effect needed repairs, inspect and audit the kitchen for compliance to professional standards for food service safety monthly for 3 months.
Dietary staff will be educated on proper food storage requirements, including expiration dates, disposal of expired food, cool down temps of leftovers, proper air gap, etc.
The faucet in the 3 compartment sink is scheduled for repair. The stove is scheduled for cleaning and Floor tiles and racks will be repaired or replaced.

The dietary manager or designee will ensure ongoing compliance. Audits will be conducted routinely and results will be shared at the facility monthly QAPI meetings.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations: Based on observation and resident and staff interview it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean, safe, and functional environment for three of four nursing units (University, Heirloom, and Nittany; Residents 7, 49, 53, 84, 109, and 121) and the facility's laundry department. Findings include: Observation of the University nursing unit nurses' station on February 18, 2026, from 9:05 AM to 9:15 AM revealed an intermittent audible sound that resonated from a wall-mounted call bell device. Interview with Employee 6 (licensed practical nurse) on the date and time of the observation confirmed that there were no resident room call bell lights visible on the University nursing unit hallways. There was no room number indicated on the screen of the wall-mounted call bell device. Employee 6 described the ongoing intermittent noise as, "a phantom call bell." Employee 6 indicated that the malfunctioning device has been an issue for approximately a year, that maintenance staff were aware through the facility's system of reporting building maintenance needs, and that staff were told by the maintenance representative that, "the wiring is old." Observation of the University nursing unit nurses' station on February 18, 2026, from 9:41 AM to 10:15 AM revealed the intermittent audible sound continued from the wall-mounted call bell device without a resident room identification. Observation of the University nursing unit nurses' station on February 19, 2026, at 12:09 PM revealed the intermittent audible sound continued from the wall-mounted call bell device without a resident room identification. Interview with Employee 6, on February 19, 2026, at 12:10 PM indicated that, "it's that phantom one again." Interview with Employee 7 (nurse aide) on February 19, 2026, at 12:30 PM indicated that the audible signal (not indicative of a resident room call bell activation) signals throughout the night. The audible noise does not stop at any time. The surveyor reviewed the above concern regarding the continuous audible noise on the University nursing unit during an interview with the Director of Nursing and the Nursing Home Administrator on February 18, 2026, at 2:00 PM. Observation of Resident 7's room on the University nursing unit on February 18, 2026, at 10:30 AM revealed a gray floor fall mat on the left side of his bed with a large amount of various colored debris and spillage. Observation of Resident 7's room on February 19, 2026, at 12:15 PM revealed his floor fall mat continued to be soiled with various colored debris and spillage. The surveyor confirmed the observation with Employee 8 (registered nurse) on February 19, 2026, at 12:17 PM. Observation on February 17, 2026, at 12:16 PM of the hallway on the Nittany unit outside the main kitchen revealed the flooring to be in disrepair. A missing floor tile was observed adjacent to a carpeted area with two chairs and a table near the exterior exit. Further review reveals multiple tiles running the entire length of the hallway are raised and peeling away from the floor. A four-foot span of tiles are noted to be held down around the edges with duct tape and masking tape, which has peeled away in places and left behind an adhesive residue. Interview with Employee 11, licensed practical nurse, on February 17, 2026, at 12:38, revealed that the facility often runs out of washcloths and instead towels, which have been cut to the size of a washcloth, are utilized. Concurrent observation of the laundry room on the Nittany nursing unit revealed a stack of 25 washcloths, more than two thirds of which were noted to have fraying edged as though they were cut up towels. Observation of the facility laundry room on February 19 ,2026, at 1:02 PM with Employee 14 (laundry supervisor) revealed there was a stack of cut of towels in the area of clean linen to be folded. Employee 14 stated the staff frequently run out of washcloths and cut up towels to use as a washcloth. Observation of Resident 84's bathroom on February 17, 2026, at 12:19 PM revealed drywall damage to the right of the mirror. Two inches of brown drywall paper is visible on either side of a soap dispenser mount. Observation of Resident 109's bedroom on February 17, 2026, at 1:10 PM revealed a heating and cooling unit was installed inside the metal casing of the previous unit. There are sharp metal edges noted to be protruding from around this casing. The new unit was smaller than the previous unit, and there were four towels rolled up filling the gap inside the unit. Additionally, multiple towels were noted to be lying across the top of the old unit casing and along the windowsill above the unit. A cold draft could be felt when standing near the window. Concurrent observations of resident 109's bedroom revealed the bedside stand had a large area of peeling varnish to the front locking drawer, measuring four by six inches. Observation of Resident 49's bathroom on February 18, 2026, at 9:56 AM revealed drywall damage to the right of the mirror. The area behind the soap dispenser was noted with brown drywall paper on either side and the damage measured two and three inches wide to the right and left sides respectively. The right corner of the bathroom above the soap dispenser was noted to have an eight-inch squared area of repaired drywall with brown water spots around the corners of the repair. The corner below the repair is noted to have paint on wall that has bubbled. The paint damage at the ceiling is six inches across, gradually narrowing to one inch and extending down three feet of the wall. Concurrent observations of Resident 49's room revealed a heating and cooling unit was installed inside the metal casing of the previous unit. There are sharp metal edges noted to be protruding from around this casing. There are multiple towels lying across the windowsill above the heating and cooling unit and around the old metal casing. Concurrent interview with Resident 49 revealed the towels are there because of a draft. The above noted concerns related the Nittany unit and Residents 84, 49, and 109, were reviewed with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:45 PM. Observation of the Heirloom unit on February 17, 2026, at 12:49 PM revealed there was a large sticky spot on the floor in the hallway upon entering the unit from the facility's main dining room. Observations made on February 18, 2026, at 10:41 AM and February 19, 2026, at 12:26 PM revealed the same sticky spot remained in the hallway on the floor. Observation of the Heirloom unit on February 18, 2026, at 10:28 AM revealed Resident 53's wall was marred next to the doorframe, and the wallpaper was peeling off the wall. Observation of the Heirloom unit on February 18, 2026, at 10:28 AM revealed Resident 121's wall was marred next to the doorframe, and the wallpaper was peeling off the wall. The above noted concerns related to Heirloom unit and Residents 53 and 121 were reviewed with the Nursing Home Administrator and Director of Nursing on February 19, 2026, at 2:12 PM 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment Previously cited 5/6/25 and 3/14/25 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e)(2.1) Management 28 Pa. Code 211.12(d)(3) Nursing services
 Plan of Correction - To be completed: 04/21/2026

The administrative team audited all occupied resident rooms on 3/3/26 and 3/5/2026 for compliance with housekeeping and maintenance services.
The intermittent audible sound could not be reproduced on either day audited, however, maintenance will monitor for the audible sound and take necessary actions to identify its source and resolve. Should other staff notice the audible sound, they will enter details into the facilities Preventive Maintenance / Work Order system, TELS.
Floor matts were cleaned on 3/4/2026. Missing floor tiles are scheduled for repair / replacement. Additional wash cloths were ordered and a par level established, wash cloths cut from towels were removed from service. PTAC Heating and air conditioning units are scheduled for re-fitting. The drywall, wallpaper and painting areas identified are scheduled to be repaired.
Maintenance or designee will audit rooms monthly for 2 months, then quarterly for 2 quarters.

483.70(m)(1)(2)(i)(ii)(3)-(5) REQUIREMENT Entering into Binding Arbitration Agreements:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.70(m) Binding Arbitration Agreements
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

§483.70(m)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(m)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;

§483.70(m)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

§483.70(m)(4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(m)(5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k).
Observations: Based on review of the facility's arbitration agreements and resident and staff interview, it was determined that the facility's arbitration agreements failed to ensure the selection of a neutral arbitrator for two of three residents reviewed with a signed arbitration agreement (Residents 93 and 118); and failed to include required regulatory language for one of three residents reviewed with a signed arbitration agreement (Resident 49). Findings include: Review of an Arbitration Agreement (an agreement that the resident/resident's responsible party and the facility will resolve legal disputes through binding arbitration, waiving their right to a trial) signed by Resident 93 on December 13, 2023, revealed that the document stipulated that, "The arbitration shall be conducted by the National Arbitration Forum (NAF)." "If the NAF process is no longer in existence at the time of dispute, or NAF is unwilling or unable to conduct the arbitration, a mutually acceptable neutral third-party alternative will be agreed to by the parties." The agreement afforded the facility the initial selection of the arbitrator (third-party decision-maker contracted to resolve a dispute). Review of an Arbitration Agreement signed by Resident 118's responsible party (daughter) on November 22, 2023, revealed that the document stipulated that, "The arbitration shall be conducted by the National Arbitration Forum (NAF)." "If the NAF process is no longer in existence at the time of dispute, or NAF is unwilling or unable to conduct the arbitration, a mutually acceptable neutral third-party alternative will be agreed to by the parties." The agreement afforded the facility the initial selection of the arbitrator. Interview with Resident 49 on February 19, 2026, at 11:40 AM revealed that he did not remember signing an arbitration agreement. Review of "Voluntary Arbitration Agreement," signed by Resident 49 on April 12, 2025, revealed that Resident 49 electronically initialed all paragraphs of the provided document, however, the document did not contain an acknowledgement to stipulate that Resident 49 understood the agreement. The document did not explicitly grant Resident 49 the right to rescind the agreement within 30 calendar days of signing it. The document did not explicitly inform Resident 49 of his right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights
 Plan of Correction - To be completed: 04/21/2026

A new and revised Admission Agreement has been implemented that, in the arbitration agreement section, it outlines that it is not a condition of admission, and in section C, that a neutral arbitrator - agreeable to both parties such as NAF.

Residents R93 and 118 were given an opportunity to execute the new / revised agreement.

No other residents / families were identified as not agreeing to binding arbitration.

All subsequent admissions will utilize the new agreement.
483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations: Based on observation, and resident and staff interview, it was determined that the facility failed to serve food at palatable temperatures on three of four nursing units (Heirloom, University, and Nittany; Residents 3, 13, 17, 89, and 93). Findings: Review of the mealtime documentation provided by the facility revealed the Heirloom food carts are scheduled to arrive on the nursing unit at 12:00 PM. Observation of the Heirloom nursing unit meal cart revealed it was observed outside the kitchen on February 19, 2026, at 11:55 AM. Observation of the lunch meal service on February 19, 2026, on the Heirloom nursing unit revealed that food trays arrived on the meal cart at 12:29 PM. Staff immediately began passing the food trays until the last tray was passed at 12:42 PM. The surveyor began testing the food temperatures of Resident 3's tray at this time with the following results: Puree ham was cold at 90.4 degrees Fahrenheit Puree mixed vegetables were cold at 92.2 degrees Fahrenheit Puree mac and cheese was cold at 91.4 degrees Fahrenheit Container of sherbert was melted Interview with Resident 17 on February 18, 2026, at 8:53 AM revealed that her food is delivered cold. Observation of the lunch meal on the University nursing unit on February 18, 2026, at 12:15 PM revealed that food trays arrived via the meal cart. Staff immediately began passing the food trays, and the surveyor began testing the food temperature of Resident 17's tray on February 18, 2026, at 12:18 PM with Employee 6 (licensed practical nurse). The chicken served on Resident 17's meal tray was cold at 107.2 degrees Fahrenheit. The surveyor reviewed the above dietary concerns on the Heirloom and University nursing units in a meeting with the Nursing Home Administrator and Director of Nursing on February 19, 2026, at 2:04 PM. Interview with Resident 93 on February 17, 2026, at 3:00 PM revealed that her food is always cold. She said it happens every day at every meal. Observation of the lunch meal on February 20, 2026, on the Nittany unit revealed the lunch trays were delivered at 12:30 PM on the food carts. The staff immediately began passing the trays and the surveyor began testing the temperature of the food on Resident 93's food tray at 12:35 PM with Employee 12 (nursing aide). The ham served on Resident 93's meal tray was cold at 94.5 degrees Fahrenheit. The surveyor discussed the dietary concerns noted on Nittany unit related to Resident 93's tray with the Nursing Home Administrator and Director of Nursing on February 19, 2026, at 3:00 PM. During an interview with Employee 11, licensed practical nurse, on February 17, 2026, at 12:38 PM, they stated that the food often arrives cold. During an interview with Resident 13 on February 17, 2026, at 1:15 PM they stated that the food temperatures are not good. Interview with Resident 89 on February 17, 2026, at 2:05 PM revealed that food often comes cold and when she asks for a substitution, such as grilled cheese, it often comes cold or very hard and difficult to eat. The concerns regarding food temperatures for Residents 13 and 89 were discussed with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:45 PM. Cross Refer 801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 211.6(a) Dietary services
 Plan of Correction - To be completed: 04/21/2026

The administrator held an ad hoc resident council meeting on 3/4/2026 where the importance of delivering meals at the proper temperature was discussed.

The regional dietary manager will be onsite and provide training and guidance to ensure that pellets are utilized and carts are delivered timely.

The facility is actively recruiting dietary staff members and will continue efforts until all positions are filled.

In the interim, we are offering incentives to current staff to ensure that resident needs are being met.

The administrator or designee will monitor progress and audit meal trays weekly for 2 weeks, then monthly for 2 months.
Results will be discussed at monthly QAPI meetings.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations: Based on observation, review of facility documents, and resident and staff interview, it was determined that the facility failed to provide menu items as indicated for the dining room and two of four nursing units (Heirloom and Nittany, Residents 51 and 89). Findings include: In an interview with Resident 51 on February 17, 2026, at 1:05 PM they stated that they often do not receive what they are supposed to on their meal tray. Review of the menu for lunch on February 19, 2026, included maple glazed ham, macaroni and cheese, Prince Edward vegetable blend, wheat dinner roll, and rainbow sherbet. During an observation of the tray line service on February 19, 2026, at 11:40 AM the plating of the meals for the dining room and Heirloom unit were observed. No wheat dinner rolls or bread was plated with the meal. Observation on February 19, 2026, at 12:18 PM on the Nittany unit of Resident 89's tray revealed that no bread was present. Observation of lunch meal service on the Heirloom unit on February 19, 2026, from 12:29 to 12:58 PM revealed there were no dinner rolls, or bread present on any of the meal trays. Observation of the kitchen supply room on February 19, 2026, at 1:30 PM, revealed three and a half racks of sliced bread, one rack of bread buns, and one rack of hoagie buns. Concurrent interview with Employee 13, dietary aide, revealed that bread was not served with the lunch meal today. Employee 13 also stated that no dietary supervisor was present today, and the bread item was not seen when checking the menu for the day. The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:45 PM. Cross Refer 801 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management
 Plan of Correction - To be completed: 04/21/2026

The administrator has met with residents R51 and R89 to discuss receiving items that are intended to be on their meal tray. With new dietary preferences clarified, diet cards for residents R51 and R89 will be updated by the regional dietary manager.
Education was provided to all dietary staff on the importance of ensuring compliance with prescribed diets.
The regional dietary manager has / will conduct an audit of all diet cards and review for accuracy / compliance with the residents prescribed diet.
The regional dietary manager or designee will continue audits of meal trays weekly for 2 weeks, then monthly for 2 months.
Results will be discussed at the facilities Monthly QAPI meeting.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations: Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Residents 17 and 100). Findings include: The facility's medication error rate was eight percent based on 25 medication opportunities with two medication errors. Observation of a medication administration pass on February 18, 2026, at 12:36 PM revealed Employee 4 (licensed practical nurse) administer Carafate (anti-ulcer medication, adheres to the stomach lining to protect it from acids and enzymes) 1 gm (gram) to Resident 17. The packaging of the Carafate medication included instructions to administer the medication on an empty stomach. Resident 17 had her lunch tray in front of her on her overbed table and was beginning to eat her lunch at the time of the medication administration. Employee 4 stated, "normally trays are not this early," as she administered the medication to Resident 17, to which Resident 17 responded, "I didn't eat a lot." Interview with Employee 4 on February 18, 2026, at 12:54 PM verified that the labeling on the Carafate medication noted to give the medication on an empty stomach, however, Resident 17 was in the process of eating her lunch at the time she took the medication. The medication reference Drugs.com instructions regarding the administration of Carafate noted, "The usual dosage for ulcer treatment is four times daily on an empty stomach (at least an hour before food and at bedtime)." Continued observation of a medication administration pass on February 18, 2026, at 12:32 PM revealed Employee 4 administered Diclofenac Sodium external gel (a nonsteroidal anti-inflammatory topical medication, works by reducing substances in the body that cause pain and inflammation) to Resident 100's bilateral knees. Employee 4 dispensed a small dollop of the gel on her gloved fingers before massaging the gel over Resident 100's knees. Clinical record review for Resident 100 revealed an active physician's order for staff to apply four grams of Diclofenac Sodium external gel topically to Resident 100's bilateral knees three times a day, not to exceed 32 grams in 24 hours. The medication reference Drugs.com instructions regarding the administration of Diclofenac Sodium gel noted that this medicine comes with a dosing card. "Be sure you know how to use it." Interview with Employee 4 on February 18, 2026, at 12:54 PM indicated that she was not aware of the process of utilizing a dosing card to measure the amount of Diclofenac Sodium gel for an accurate dose of four grams. Observation of the medication packing revealed a plastic dosing card that permitted the user to dispense different amounts for either a two-gram or a four-gram dose. Observation of the medication's box also included a diagram of the approximate length of gel used to administer a two-gram dose or a four-gram dose. The surveyor reviewed the above two medication error concerns during an interview with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:00 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services
 Plan of Correction - To be completed: 04/21/2026

Resident 17 and 100 had no ill effects r/t medication discrepancies.

All nursing staff will be educated on the administrating medications in accordance with physician orders as well as specified dosing cards.

The facility will ensure that the residents noted in the citation will get the medications as ordered and administered according to manufacturers guidelines.

The RN supervisors/designee to identify any other residents that may be impacted.

DON/Designee will conduct weekly medication pass audits to ensure medication guidelines are followed per physician orders for 4 weeks.

483.25(n)(1)-(4) REQUIREMENT Bedrails:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

§483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

§483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations: Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to obtain informed consent prior to the installation of bedrails for two of eight residents reviewed (Residents 8 and 11), and failed to assess all potential risks for entrapment for five of eight residents reviewed for bedrail use (Residents 4, 8, 9, 11, and 93). Findings include: The facility policy entitled, "Bed Rail Procedure," last reviewed without changes on January 21, 2026, revealed that if a resident is appropriate for a bed rail, nursing and/or designee will complete a Bed Rail Education/Consent with the resident and/or responsible party. Note, consent must be completed prior to bed rail(s) being placed on the resident's bed. Nursing will place a request for bed rails in TELS (maintenance communication system). Maintenance will confirm that consent/education was completed before placing bed rails to the bed, will install bed rails as requested, will ensure that manufacturer's recommendations and specifications are followed for bed rails being placed, and will conduct quarterly inspection of all beds with bed rails as part of a regular maintenance program to identify areas of possible entrapment. Housekeeping will notify maintenance of the discharge or transfer of a resident to remove bed rails. Ambassadors are to look for empty beds with bed rails to request removal via TELS. The Maintenance Bed Rail Evaluation noted seven zones evaluated for entrapment risk; and noted to refer to facility policy. A diagram identified seven potential entrapment zone locations on a bed equipped with bed rails. Zone six was defined as between the end of the rail and the side of the head or foot board. The Dimensional Guidelines for Entrapment Zones noted specific measurements for zones one through five; however, had no measurements noted for zones six or seven. Observation of Resident 11's room on February 18, 2026, at 11:17 AM revealed that her bed was equipped with a headboard, footboard, and bilateral assist bed rail devices. Interview with Resident 11 on the date and time of the observation revealed that she recently moved rooms although she was unsure of the exact date or reason for the move. Clinical record review for Resident 11 revealed no documented assessment for the need for, consent for the use of, or entrapment risk assessment regarding the bed rails. Interview with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:00 PM revealed that staff who facilitated Resident 11's room change (on February 8, 2026) did not exchange Resident 11's bed; and allowed her to use the bed that was in the room she transferred to. Staff submitted a maintenance request to have enabler bars removed on February 11, 2026 (three days after Resident 11 moved to a new room), however, this was not done as of the time of the onsite survey. The facility failed to assess Resident 11 for the risk of entrapment from bed rails prior to her use of her bed, failed to review the risks and benefits of bed rails to obtain informed consent prior to her use of her bed, and failed to assess that her new bed's dimensions were appropriate for her size and weight. Observation of Resident 8's room on February 18, 2026, at 10:52 AM revealed him in his bed that was equipped with bed rail assist devices bilaterally at the head of his bed, a headboard, and a footboard. Clinical record review for Resident 8 revealed an active physician's order dated January 5, 2026, for bilateral enabler bars on his bed for bed positioning and bed mobility. A Bed Rails Informed Consent for Use was not dated; and did not include an acknowledgement or signature to attest that Resident 11 and/or his responsible party consented to the use of the devices. A Maintenance Bed Rail Evaluation dated January 5, 2026, noted that maintenance staff checked the boxes that seven zones were evaluated for entrapment risk. Interview with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:00 PM confirmed that the facility had no signed consent for Resident 8's use of bed rails. Observation of Resident 4's room on February 18, 2026, at 11:10 AM revealed her to be in her bed that was equipped with bed rail assist devices bilaterally at the head of her bed, a headboard, and a footboard. Clinical record review for Resident 4 revealed an active physician order dated June 14, 2024, for bilateral enabler bars to aide with turning and repositioning. A Maintenance Bed Rail Evaluation dated January 5, 2026, noted that maintenance staff checked the boxes that seven zones were evaluated for entrapment risk. Observation of Resident 9's room on February 18, 2026, at 11:20 AM revealed her sitting in a chair beside her bed. Her bed was noted to be equipped with bedrail assist devices bilaterally. Concurrent interview with Resident 9 revealed that she utilized the bedrail assist devices to help her move in bed. Clinical record review for Resident 9 revealed an active physician's order dated February 11, 2026, for bilateral enabler bars to aid with turning and repositioning. A Maintenance Bed Rail Evaluation dated February 11, 2026, noted that maintenance staff checked the boxes that seven zones were evaluated for entrapment risk. Observation of Resident 93's room on February 17, 2026, at 3:12 PM revealed her in her bed with bedrail assist devices bilaterally. Concurrent interview with Resident 93 revealed that she used the bedrails to help move herself in bed. Clinical record review for Resident 93 revealed that there was no current physician's order for her bilateral bedrail assist devices until February 19, 2026, after the surveyor discussed Resident 93's bilateral assist devices with the facility during a meeting on February 18, 2026, at 2:45 PM. A Maintenance Bed Rail Evaluation for Resident 93 dated January 10, 2026, noted that maintenance staff checked the boxes that seven zones were evaluated for entrapment risk. Interview with Employee 10 (maintenance director) on February 20, 2026, at 11:26 AM confirmed that although he was documenting that zones six and seven posed no entrapment risk, he had no parameter or expectation of a measurement or finding that would meet a criterion to determine that there was no entrapment risk (e.g., a range of measurements or angle degrees) for zones six or seven. Employee 10 confirmed that neither zone had an established range or measurement within the facility policies or procedures. Employee 10 stated that he would expect no gaps (e.g., measurement of zero) when he assessed zone seven, however, he had no parameter for zone six. The surveyor reviewed the above concerns regarding the facility's policy and procedure for bed rail/assist bar assessments during an interview with the Nursing Home Administrator and the Director of Nursing on February 20, 2026, at 11:45 AM. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 04/21/2026

Resident R-11 and R-8 have been scheduled for therapy screen for bed safety. R-11 and R-8 bed was measured and reviewed for safety and was found to be compliant. No non compliant beds were identified.
A whole house audit of bed rails and written consent will be conducted and care plans / orders will be reviewed to ensure compliance.
Measurements for zone 6 and 7 were also provided to maintenance. Beds for residents R4,R8,R9,R11 and R93 were found to be compliant.
To ensure ongoing compliance, the director of nursing will ensure therapy screens of all new admissions for bed safety / use of side rails. The DON will also ensure informed consent is received and documented for use of side rails.
Audits of bed rail use will be conducted weekly for 2 weeks, then monthly for 2 months.
Results will be presented at QAPI.

483.10(e)(4)-(6) REQUIREMENT Choose/Be Notified of Room/Roommate Change:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

§483.10(e)(5) The right to share a room with his or her roommate of choice when practicable, when both residents live in the same facility and both residents consent to the arrangement.

§483.10(e)(6) The right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.
Observations: Based on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that written notice, including the reason for a room change, was provided to a resident prior to a facility-initiated room change for one of one resident reviewed for concerns related to resident choice (Resident 11). Findings include: Interview with Resident 11 on February 18, 2026, at 11:15 AM revealed that she, "...got room moved and do not know why, staff just came in and started taking stuff out of closets and drawers and was moved that day." Resident 11 further stated, "I'm not cattle, they could have talked to me about it. I speak English and understand what they say." Clinical record review for Resident 11 revealed census information that she did reside in the same room from November 18, 2024, to February 8, 2026, when she moved to her current room. Nursing documentation by the registered nurse dated February 8, 2026, at 12:17 PM noted, "We spoke with resident about moving rooms and she agreed she is okay with moving rooms, I also called and left a message for her daughter so she would know we moved her room." Resident 11's clinical record contained no evidence that written documentation was given to Resident 11 and/or her responsible party of why the room move was required. The facility also could provide no documentation to evidence that Resident 11 was given the opportunity to see the new location or meet her new roommate. The surveyor reviewed the above concerns regarding Resident 11's room and roommate change during an interview with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:00 PM. The interview confirmed that there was no written documentation given to Resident 11 and/or her responsible party of why the room move was required. The facility also could provide no documentation to evidence that Resident 11 was given the opportunity to see the new location or meet her new roommate. 28 Pa. Code 201.14(a) Responsibility of licensee 29 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3) Nursing services
 Plan of Correction - To be completed: 04/21/2026

NHA met with resident R-11 on 3/4/2026 and apologized for not discussing the room move with her / family in advance.
After interviewing residents with recent room moves, it was determined that no others were in a similar situation.
The facility will provide training to nursing staff on compliance with room move practices, including required written notification of the pending move, the reason for the move and the right to refuse.
The NHA or designee will audit room moves weekly for 2 weeks, then monthly for 2 months. Results will be presented at QAPI.

483.10(f)(10(i)(ii) REQUIREMENT Protection/Management of Personal Funds:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(f)(10) The resident has a right to manage his or her financial affairs. This includes the right to know, in advance, what charges a facility may impose against a resident's personal funds.
(i) The facility must not require residents to deposit their personal funds with the facility. If a resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in this section.
(ii) Deposit of Funds.
(A) In general: Except as set out in paragraph (f)( l0)(ii)(B) of this section, the facility must deposit any residents' personal funds in excess of $100 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain a resident's personal funds that do not exceed $100 in a non-interest bearing account, interest-bearing account, or petty cash fund.
(B) Residents whose care is funded by Medicaid: The facility must deposit the residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.) The facility must maintain personal funds that do not exceed $50 in a noninterest bearing account, interest-bearing account, or petty cash fund.
Observations: Based on clinical record review, facility documentation review, and resident and staff interview, it was determined that the facility failed to obtain written authorization to manage personal funds for one of two residents reviewed for personal funds concerns (Resident 12). Findings include: Interview with Resident 12 on February 18, 2026, at 9:23 AM revealed that the business office in the facility held money for him, that a cousin deposited a check in that account for him, but that he did not receive a statement or had knowledge of how much money was in the account. Clinical record review for Resident 12 revealed a Resident Personal Funds agreement dated November 7, 2022, that Resident 12 signed to elect to manage his own funds (declined to have the facility manage his funds). A Resident Fund Management Service (RFMS) Authorization and Agreement to Handle Resident Funds form signed by Resident 12 on November 8, 2022, declined an RFMS account. A Resident Personal Funds agreement dated November 5, 2024, signed by Resident 12, again documented his election to manage his own funds (declined to have the facility manage his funds). An RFMS Authorization and Agreement to Handle Resident Funds form signed by Resident 12 on November 5, 2024, again documented his declination to establish an RFMS account. An Authorization Agreement for pre-authorized payments signed by Resident 12 on January 22, 2025, permitted the facility to automatically withdraw a monthly amount not to exceed $2000.00 from his bank's checking account. Review of an RFMS statement dated from December 15, 2025, to February 17, 2026, indicated that Resident 12's monthly payments, care cost debits, interest payment, and a credit adjustment resulted in a $191.88 credit balance in the account. The surveyor requested the written authorization completed by Resident 12 to establish a personal fund during an interview with the Nursing Home Administrator and the Director of Nursing on February 18, 2026, at 2:00 PM. An interview with Employee 2 (business office manager), the Director of Nursing, and the Nursing Home Administrator, on February 20, 2026, at 11:45 AM confirmed that Resident 12 authorized the facility to withdraw his personal liability payment from his personal checking account monthly, however, there was no evidence that he provided written authorization to establish an RFMS account. 28 Pa. Code 201.18(b)(2)(e)(1) Management 28 Pa. Code 201.29(a) Resident rights
 Plan of Correction - To be completed: 04/21/2026

The administrator met with resident R12 and ensured that he is indeed managing his own funds.
Education was provided to the business office manager on residents choice to manage their own funds.
Audits of all residents found no others in similar situations.
Audits of admissions will be conducted weekly for 3 weeks, then monthly for 2 months.
The NHA or designee will audit admissions for choice in funds management weekly for 2 weeks, then monthly for 2 months. Results will be presented at QAPI.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations: Based on clinical record review and staff interview, it was determined that the facility failed to establish clear end of life directives for one of six residents reviewed (Resident 13). Findings include: A review of Resident 13's clinical record revealed an active physician's order dated November 19, 2025, that indicated the resident was a DNR (do not resuscitate, do not attempt CPR (cardiopulmonary resuscitation) when the person has no pulse and is not breathing) and stated, "DNR (Do Not Resuscitate)-LIMITED: NO INTUBATION, use medical treatment, IVF, ABX Discussed with daughter, new POLST completed." Resident 13's POLST (Pennsylvania Orders for Life-Sustaining Treatment, a form directing medical staff to complete life-sustaining treatment or allow a natural death) dated on November 18, 2025, was noted to be signed by the resident's daughter due to confusion at that time. Clinical record review for Resident 13 revealed a quarterly MDS (Minimum Data Set, an assessment completed at periodic intervals of time to assess resident care needs), dated December 28, 2025, in which facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status, used to evaluate aspects of cognition such as attention, orientation, and memory recall) score of 15, the highest possible score, indicating a normal level of cognition. The resident was noted to have a previous POLST dated September 19, 2025, signed by the resident which indicated a desire for CPR and full medical treatment. No evidence was found that the facility discussed the change of code status with Resident 13 to confirm the resident's wishes for the change in end-of-life care. This was confirmed with the Nursing Home Administrator and the Director of Nursing during a meeting on February 20, 2026, at 11:20 AM. Resident was unavailable for further interview due to a medical procedure. 483.10(c)(6)(8)(g)(12)(i)-(v) Request/Refuse/Discontinue Treatment; Formulate Adv Dir Previously cited deficiency 3/14/25 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 28 Pa. Code 201.29(a) Resident rights
 Plan of Correction - To be completed: 04/21/2026

Resident #13 code status and advanced directive wishes reviewed with resident, new POLST form completed based on residents' preferences. Physician order updated to reflect residents POLST form
An Audit will be conducted by DON/ and or Designee of all residents with a BIMS of 13 or higher to ensure the opportunity to formulate their own POLST Form.
All licensed staff to ensure POLST are completed and/or reviewed by cognitive residents on admission or readmission. Review of Advanced Directive Policy.
A random weekly audit will be conducted on all new admissions and re-admissions by DON/designee to ensure that residents with cognitive ability are given the opportunity to complete POLST Form and ensure wishes are followed weekly X 4 weeks.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations: Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies a potential allegation of misappropriation of resident property for one of 24 records reviewed (Resident 30). Findings include: The facility policy entitled "Abuse, Neglect, and Exploitation," last reviewed without changes on January 21, 2026, revealed an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect, or exploitation occur. The facility will report all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies (i.e. law enforcement, when applicable) within specified timeframes, not later than 24 hours if the events that cause the allegation do not involve abuse, and do not result in serious bodily injury. Nursing documentation dated January 23, 2026, at 2:25 PM revealed Resident 30 put her husband on the phone with Employee 5 (licensed practical nurse). Resident 30's husband told Employee 5 when Resident 30 was on the Heirloom nursing unit she had a wallet with cards and $128.00 in it and the staff on the Heirloom nursing unit took Resident 30's wallet and locked it up. Employee 5 did not know anything about a wallet but told Resident 30's husband that she would talk to the Heirloom staff and see if they had Resident 30's wallet. Employee 3 (social worker) revealed she spoke with the Heirloom nurse, and the nurse stated they did not take anything from Resident 30 and lock it up, indicating she checked all areas and there was no wallet in any of those areas. Employee 3 notified Employee 1 (assistant director of nursing) and let her know what Resident 30's husband and Heirloom staff stated. Further review of Resident 30's clinical record revealed no investigation into Resident 30's allegation of the potential misappropriation of Resident 30's wallet and contents. During a meeting with the Nursing Home Administrator and Director of Nursing on February 18, 2026, at 2:11 PM they stated Resident 30 did not have a wallet. Nursing documentation dated February 18, 2026, at 5:49 PM, noted Resident 30's purse with money and belongings had been located, and the purse, money, and belongings were returned to Resident 30's husband. Interview with the Nursing Home Administrator and Director of Nursing on February 19, 2026, at 2:08 PM confirmed the above findings for Resident 30. The facility failed to complete an investigation, obtain witness statements, notify law enforcement, or notify Department of Health related to Resident 30's husband allegation of a potential misappropriation of resident property. 483.12 (b) Development and Implementation of Abuse Policy Previously cited June 11, 2025 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(b)(1)(3)(e)(1) Management 28 Pa Code 201.19(8) Personnel policies and procedures
 Plan of Correction - To be completed: 04/21/2026

Resident 30 belongings were found, and the husband took items home
An audit will conducted for last 30 days of concerns forms/ missing item forms to ensure that investigation and reporting is complete for any missing items as indicated by DON/designee
All staff will be educated on the procedure of reporting missing items and the Abuse policy with reporting requirements by DON/designee.
DON/ Designee will audit ongoing concern forms weekly to ensure that procedure is followed with any missing items and reporting it completed as indicated X4 weeks.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations: Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive, person-centered care plan for suicidal ideations one of 24 residents reviewed (Resident 101). Findings include: Clinical record review revealed the facility admitted Resident 101 on September 22, 2025. Nursing documentation dated January 30, 2026, at 2:55 PM noted Resident 101 was very tearful, stating she was scared and wanted to go home. Documentation revealed Resident 101 stated she wanted a straight razor because if she does not do it to herself, this place will, stating she would be better off dead. Documentation revealed the facility contacted Resident 101's daughter and she was unable to calm Resident 101. The facility placed Resident 101 on every 15-minute checks. Review of Resident 101's care plan on February 20, 2026, revealed no comprehensive, person-centered care plan that addressed Resident 101's suicidal ideation. Interview with Employee 3 (social worker) on February 20, 2026, at 1:11 PM confirmed the above findings for Resident 101 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 04/21/2026

Resident 101 has since CTB from natural causes unrelated to this event. R101 had no further ideations of self harm. The facility is unable to retrospectively correct as it relates to R101.
Education will be provided to all staff on recognizing and responding to indications or ideations of self harm.
Social Services staff or designee will audit notes of other residents in similar situations and will ensure that proper plans of care are in place.
Audits will continue weekly for 2 weeks, then monthly for 2 months.
Results of the social services audit will be discussed at QAPI.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations: Based on clinical record review and resident and staff interview, it was determined that the facility failed to assist dependent residents with activities of daily living for two of two residents reviewed for activities of daily living concerns (Residents 11 and 8). Findings include: Clinical record review for Resident 11 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated January 28, 2026, that staff determined Resident 11 needed partial/moderate staff assistance for showering/bathing. Review of a plan of care initiated by the facility on November 20, 2024, to address Resident 11's care preferences, revealed interventions that included that staff honor that Resident 11 stated that she preferred a shower in the morning. Resident 11 is scheduled for a shower on day shift. Review of a plan of care initiated by the facility on November 19, 2024, to address assistance Resident 11 needed for activities of daily living (ADLs), revealed that Resident 11 needed staff supervision for bathing and personal hygiene. During an interview with Resident 11 on February 18, 2026, at 11:16 AM she stated, "I haven't had a shower in quite a while. I think it is twice a week I'm supposed to get a shower. I think because the move (room assignment moved)." Review of Resident 11's Documentation Survey Report (electronic documentation completed by nurse aide staff for the completion of ADL care) dated January and February 2026 revealed that staff failed to document the completion of morning care, evening care, and bathing/showering on the following occasions: Morning (AM shift) care was not applicable/not done on January 6, 10, 11, 2026 Evening (evening shift) care was not applicable/not done on January 2, 5, 9, 10, 11, 12, 14, 16, and 22, 2026; and February 9, 13, 16, and 17, 2026 Resident 11 did not receive a shower on January 8 and 15, 2026 (staff documented the completion of only a partial bath) Interview with Employee 1 (assistant director of nursing) and the Director of Nursing on February 20, 2026, at 11:25 AM confirmed that Resident 11's assessed need and preferences for ADL care were not followed by staff as documented on the above occasions. Clinical record review for Resident 8 revealed an admission MDS assessment dated January 4, 2026, that staff determined Resident 8 needed substantial/maximal staff assistance for showering/bathing and that he was dependent on staff for personal hygiene. Review of a plan of care initiated by the facility on December 31, 2025, to address Resident 8's care preferences, revealed interventions that included staff honor that Resident 8 stated he preferred a shower in the morning. Resident 8 was scheduled for a shower on day shift. Review of a plan of care initiated by the facility on December 30, 2025, to address assistance Resident 8 needed for ADLs, revealed that Resident 8 needed extensive staff assistance for bathing and limited staff assistance for personal hygiene. Review of Resident 8's Documentation Survey Report dated January and February 2026 revealed that staff failed to document the completion of morning care, evening care, and bathing/showering on the following occasions: Morning (AM shift) care was not applicable/not done on January 7 and 29, 2026; and February 8, 2026 Evening (evening shift) care was not applicable/not done on January 3 and 23, 2026 Resident 8 did not receive a shower on January 7, 11, 14, 21, and 25, 2026 (staff either omitted documentation, documented as not applicable, or documented the completion of only a partial bath). Resident 8 received only one shower from February 1 through 18, 2026, as staff documented a bed bath on February 4, 2026, not applicable on February 7, 2026, and a partial bath on February 11, 2026. Interview with Employee 1 and the Director of Nursing on February 20, 2026, at 11:25 AM confirmed that Resident 8's assessed need and preferences for ADL care were not followed by staff as documented on the above occasions. 28 Pa. Code 211.12(d)(1)(5) Nursing services
 Plan of Correction - To be completed: 04/21/2026

Residents 8 and 11 have been interviewed for bathing preferences, plan of care has been updated with resident's preferences.
An audit will be conducted by DON/Designee to review all residents' preferences are being followed along with plan of care (Kardex) reflects residents' preferences
Direct care staff will be educated by DON or Designee on following care preferences and ensuring Documenting and Reviewing Kardex to meet resident needs/ preference
DON/Designee will conduct weekly random audits to determine if resident's preferences are being met and plan of care (Kardex) reflects resident's current plan X4 weeks.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations: Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for two of six residents reviewed for ROM concerns (Residents 59 and 118). Findings include: Clinical record review revealed the facility admitted Resident 59 on August 8, 2025. Review of Resident 59's most recent quarterly MDS (Minimum Data Set, an assessment completed at specific intervals to determine care needs) dated January 20, 2026, noted staff assessed Resident 59 as having impairment to his range of motion (ROM, movement of the body to maintain a resident's ability) of one side of his upper extremities. Review of Resident 59's discharge progress note from occupational therapy dated September 30, 2025, indicated discharge recommendations for a restorative nursing program. There was no evidence in Resident 59's clinical record that Resident 59 received a passive range of motion program. Review of Resident 59's therapy discharge recommendation sheet dated and signed by therapy on January 5, 2026, indicated that he was to have an exercise program that consisted of bilateral upper extremity passive range of motion. There was no evidence in Resident 59's clinical record that he was provided the passive range of motion program as recommended by therapy on January 5, 2026. Clinical record review for Resident 118 revealed that the facility admitted her on November 22, 2023. Review of Resident 118's most recent quarterly MDS dated January 21, 2026, revealed that she had and impairment of her bilateral lower extremities. Interview of Resident 118 on February 18, 2026, at 12:04 PM revealed that she was on physical therapy, but it was discontinued a couple of weeks ago. She indicated that she was to have exercises completed by nursing staff to both her legs, but they did not start them yet. Review of Resident 118's physical therapy discharge summary dated February 6, 2026, revealed discharge recommendations for lower extremity exercises. The discharge summary indicated that a restorative program was not established at this time, but a functional maintenance program was established and trained for range of motion. The discharge summary also indicated that the program was established and trained and that Resident 118's prognosis to maintain current level of functioning was good with consistent staff follow-through. Interview with the Director of Nursing and Nursing Home Administrator on February 19, 2026, at 2:48 PM revealed that the functional maintenance program is completed by the nursing staff and would be considered a range of motion program. Interview with the Director of Nursing on February 20, 2026, at 11:12 AM revealed that the facility had no evidence that Resident 118's ROM program was being completed as recommended. The facility failed to ensure Residents 59 and 118 received appropriate treatment and services to maintain or prevent further decrease in their range of motion. 483.25(c) Mobility Previously cited 3/14/25 28 Pa. Code 211.12(d)(1)(5) Nursing services
 Plan of Correction - To be completed: 04/21/2026

Residents 59 and 118 were evaluated for appropriateness of restorative nursing program, program implemented and plan of care updated to include restorative nursing program.
DON/designee will complete a review of residents discharged within the last 60 days from therapy to ensure that Restorative Nursing Programs were developed and implemented as indicated.
DON/designee will complete education to all licensed staff and therapy departments on restorative planning processes, protocols and implementation of restorative programs.
DON/Designee will complete weekly audits of resident completing therapy services to ensure that restorative programs have been implemented, and plan of care updated to meet residents' needs as indicated by therapy recommendations.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations: Based on clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to implement a CPAP (continuous positive airway pressure) machine as recommended by a physician for one of one resident reviewed for oxygen concerns (Resident 93). Findings include: Interview with Resident 93 on February 17, 2026, at 3:13 PM revealed that her cardiologist was upset that she still does not have a CPAP machine (a device used to treat sleep apnea by delivering a steady gentle stream of pressurized air through a mask to keep the airway open during sleep). She indicated that her cardiologist had asked for her to have a CPAP machine three times now. She also indicated that the staff have never discussed the CPAP machine with her. Review of a cardiology consult visit form dated September 26, 2024, indicated that the cardiologist wanted the facility to get Resident 93's CPAP as she was on it at home. Further clinical record review for Resident 93 revealed cardiologist visit note dated March 18, 2025, that indicated he strongly recommends Resident 93 receives CPAP therapy for her obstructive sleep apnea. Clinical record review for Resident 93 revealed a progress note dated April 14, 2025, at 1:22 AM that indicated resident had a cardiology appointment on March 18, 2025, and recommendations for Resident 93 to receive CPAP therapy for her obstructive sleep apnea were sent to the nurse practitioner who indicated that Resident 93 had refused a CPAP machine in the past when suggested to her. The note indicated that the nurse went to the room to speak with Resident 93 but that she was asleep and she would attempt again in the morning. There was no further documentation noted related to Resident 93 and CPAP therapy. Interview with the Director of Nursing on February 19, 2026, at 2:44 PM revealed that the nurse practitioner revealed to her that she did have the discussion with Resident 93 regarding the CPAP machine and she refused it. There was no documentation to confirm that the nurse practitioner had a discussion with Resident 93 related to the CPAP machine. The facility failed to offer or provide Resident 93 with a CPAP machine as recommended by her cardiologist. The Nursing Home Administrator and Director of Nursing were made aware of the above noted concerns related to Resident 93's CPAP therapy on February 20, 2026, at 11:30 AM. 28 Pa. Code 211.12(d)(1)(5) Nursing services
 Plan of Correction - To be completed: 04/21/2026

Resident #93 orders for CPAP reviewed, resident assessed by in-house respiratory therapist and physician. Residents plan of care updated to meet residents' needs.
An audit will be conducted on residents utilizing CPAP devices to ensure orders are being followed and documented in place audit to be completed by respiratory therapists/designee.
DON/ Designee will complete education to all licensed staff on the importance of following consulting recommendations and implementation of recommendations once approved by attending physician.
DON/Designee will complete weekly audits of all new admissions for use of CPAP and orders being followed. DON/designee will also audit consult forms from outside medical appointments to ensure that recommendations are reviewed and implemented as indicated weekly X4 weeks.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations: Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to secure medications on one of four nursing units (Nittany, Residents 13 and 51). Findings include: Observation of Resident 51's room on February 17, 2026, at 1:05 PM revealed an eye dropper container of Refresh Tears (artificial tears designed to provide temporary relief from dry eyes, irritation, and discomfort caused by insufficient tear production) on their bedside table. During a concurrent interview with Resident 51, they stated that the facility was aware they had the eye drops in their room. Observation of Resident 13's room February 17, 2026, at 1:15 PM revealed an eye dropper container of Genteal Tears (eye drops used to relieve dry, irritated eyes) on their bedside table. There was no evidence Resident 51 or Resident 13 was evaluated or ordered to self-administer the eye drops as indicated above and the eye drops were stored in the resident's room. The Nursing Home Administrator and the Director of Nursing were made aware of the above findings on February 19, 2026, at 2:15 PM. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 04/21/2026

Unsecured medications were removed from residents 13 and 51 rooms. Education provided to residents on medication storage policy.
RN Supervisor/designee will conduct audits of all rooms to ensure that medication is properly stored
DON or designee will educate staff on storage requirements of medication and the need to keep medication for safety reasons.
RN Supervisors/ designee will complete audits Weekly for any unsecured medications and ensure proper medication storage X4 weeks

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations: Based on clinical record review and staff interview, it was determined that the facility failed to provide routine dental services for two of four residents reviewed for dental concerns (Residents 2 and 30). Findings include: Clinical record review revealed the facility admitted Resident 30 on March 18, 2025. Observation of Resident 30 on February 17, 2026, at 11:08 AM revealed Resident 30 was in the dining room. Observation of Resident 30's mouth revealed several broken teeth. Review of Resident 30's admission MDS (Minimum Data Set, an assessment completed by the facility, at intervals to determine the care needs of the resident) dated March 24, 2025, revealed that she had some of her own natural teeth and that she had obvious or was likely to have cavities or broken teeth Review of Resident 30's care plan-initiated April 6, 2025, revealed Resident 30 is at risk for dental or chewing problems related to missing and broken teeth. Further review of Resident 30's clinical record revealed Resident 30 was not seen by the facility's consultant dentist since admission and was not seen by a dental hygienist until February 3, 2026. There was no documentation that indicated Resident 30 was offered routine dental services every six months as the State Plan allows. The above findings for Resident 30 were reviewed with the Nursing Home Administrator and Director of Nursing on February 20, 2026, at 11:55 AM. Interview with Employee 3 (social worker) confirmed Resident 30 did not receive dental care according to the State Plan. Clinical record review for Resident 2 revealed that the facility admitted her on March 23, 2023. Observation of Resident 2 on February 19, 2026, at 11:30 AM revealed her to have some broken teeth. Review of Resident 2's annual MDS dated December 15, 2025, revealed that she had some of her own natural teeth and that she had obvious or was likely to have cavities or broken teeth. Review of Resident 2's care plan that was initiated June 25, 2023, revealed that Resident 2 is at risk for dental or chewing problems related to broken teeth. Review of Resident 2's clinical record revealed that she was seen by the dental hygiene practitioner on November 14, 2025, but the facility was unable to provide information regarding the last time Resident 2 was seen by the facility's consulting dentist. There was no documentation that indicated Resident 2 was offered routine dental services every six month as allowed by the State Plan. The above noted findings for Resident 2 were reviewed with the Nursing Home Administrator and Director of Nursing on February 20, 2026, at 11:45 PM. 28 Pa. Code 201.18(d) Management 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
 Plan of Correction - To be completed: 04/21/2026

Resident 2 and resident 30 have been offered dental services, both will be placed on list for next in-house dental visit.
Social service director/designee will conduct audits on residents who are appropriate for dental services to ensure dental services have been offered and provided services if agreeable.
Administrator will provide education to administrative staff on dental services and requirements.
Service Director will complete an audit of new admissions that will be conducted to ensure that dental services are being offered and or provided as indicated weekly for 2 weeks, then monthly for 2 months.
Results of all audits will be reported at QAPI.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations: Based on observation, review of facility documents, and resident and staff interview, it was determined that the facility failed to provide food and drink to accommodate individualized preferences for one of 24 sampled residents. (Resident 89). Findings include: Interview with Resident 89 on February 17, 2026, at 2:05 PM revealed that despite explaining to the facility that she is vegetarian, eating only occasionally some chicken or turkey, she is continually served meat. Resident 89 stated she was served ham for breakfast this morning and received the meat at lunch (menu reveals that the meat was Salisbury steak). Resident 89 also stated that she only receives water to drink and she does not receive ice. Evidence the facility obtained food preferences/choices for Resident 89 was requested from facility staff on February 18, 2026, at 2:30 PM but was not provided during the survey. Interview with Resident 89 on February 19, 2026, at 9:36 AM revealed that she received bacon for breakfast that morning and only received water as her beverage without ice. Review of Resident 89's dietary meal ticket revealed that pork and pork products and beef products were listed on the ticket as dislikes for the resident, and no beverages were listed. During an interview with the Nursing Home Administrator on February 19, 2026, at 2:40 PM, she stated that if the resident's dislikes listed all pork products and beef products, it would likely indicate the resident may be vegetarian. Resident 89's food and beverage preferences were not honored as noted above. The above information was reviewed with the Nursing Home Administrator and the Director of Nursing on February 19, 2026, at 2:45 PM. 201.14(a) Responsibility of licensee
 Plan of Correction - To be completed: 04/21/2026

Resident R89's diet preferences were updated and clarified to reflect her current likes and dislikes.
An audit of resident preferences was completed on 3/3/26 and 3/4/26 and no other non-compliances were noted.
Education for all staff was provided on the importance of ensuring diet compliance to the residents preferences per the meal ticket.
A random audit will be completed of resident likes/dislikes will be conducted weekly for 2 weeks and monthly for 2 months. Updates will be made as needed.
Results of audits will be shared at monthly QAPI meetings.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations: Based on staff interview and review of facility documentation, it was determined that the facility did not comply with the multidisciplinary committee requirements of the Act 52 Infection Control Plan. Findings include: Act 52 Infection Control Plan, states that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable to the specific health care facility: (i) Medical staff that could include the chief medical officer or the nursing home medical director (ii) Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator (iii) Laboratory personnel (iv) Nursing staff that could include a director of nursing or a nursing supervisor (v) Pharmacy staff that could include the chief of pharmacy (vi) Physical plant personnel (vii) A patient safety officer (viii) Members from the infection control team, which could include an epidemiologist. (ix) The community, except that these representatives may not be an agent, employee, or contractor of the health care facility. Review of facility-provided Infection Control Prevention Committee (ICPC) attendance records dated April 24, 2025, July 24, 2025, December 17, 2025, and January 21, 2026, revealed that the facility established a quarterly schedule for infection control committee meetings. There was no evidence that the facility included any physical plant personnel or patient safety officer. The documentation indicated that the facility's pharmacy representative attended only one of the four meetings. The laboratory personnel attended only one of the four meetings The community representative that attended the meetings was an employee from the facility's medical director's group (not someone outside the agents/employees/contractors of the facility). Interview with Employee 1 (infection preventionist) on February 20, 2026, at 9:47 AM confirmed the above findings regarding the infection control committee members and meeting attendance.
 Plan of Correction - To be completed: 04/21/2026

The infection preventionist was educated on the importance of quorum at this meeting.
The administrator or designee will ensure compliance for all future meetings. In the event that quorum is not met, due to unforeseen circumstance, the meeting will be rescheduled for an asap date.

A 6 month advanced schedule will be established for subsequent meetings, including Outlook calendar reminders.

The administrator will report meeting compliance at the monthly QAPI meeting.

§ 211.5(i) LICENSURE Medical records.:State only Deficiency.
(i) The facility shall assign overall supervisory responsibility for the medical record service to a medical records practitioner. Consultative services may be utilized; however, the facility shall employ sufficient personnel competent to carry out the functions of the medical record service.

Observations: Based on staff interview it was determined that the facility failed to employ sufficient staff to carry out the functions of the medical record service. Findings include: Interview with the Director of Nursing on February 17, 2026, at 11:00 AM revealed that residents' medical records are documented within an electronic medical record system (EMRS); however, there is a backlog of documents (a large stack of paperwork) not currently scanned into the EMRS due to the omission of a medical records staff position. The tasks of medical records have become an assigned function of nursing administration. The interview confirmed that the facility had no medical records practitioner or consultative service for approximately two to three months, and there were no plans to staff that position.
 Plan of Correction - To be completed: 04/21/2026

The administrator has secured an agreement with a contracted / certified (RHIA) medical records practitioner on 3/13/2026.

The RN supervisor or designee on overnight shift will scan in backlogged records.

Visits will be scheduled for monthly for 3 months, then quarterly thereafter.

The administrator or designee will ensure compliance to this schedule via monthly audits and will report results to the facilities monthly QAPI meeting.


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