Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of Hearthside during CMS and state inspections, most recent first.
Food and nutrition services staffing deficiency: the facility did not employ a full-time qualified director of food and nutrition services in the absence of a full-time RD. A certified dietary manager was only working one day a week to help until a new director was obtained, and the NHA stated the RD was only used on an as-needed basis.
Housekeeping and maintenance failures were observed in multiple shower rooms and an outdoor breezeway. The Heirloom unit shower room had a strong musty odor and black buildup in the grout, the University unit shower room had dirt/debris in the tub, stained and damaged curtains, scattered unlabeled items, and a dirty toilet area, and the [NAME] unit shower room had black buildup, clutter in the tub, an unbagged toilet riser, and marred surfaces. The breezeway drain also had a broken metal cover resting inside the drain hole.
Food storage and kitchen sanitation were deficient in the main kitchen. An overflowing trash can, dirty receiving and dry storage floors, a dusty ice dispenser with parts on top, food stored on open wire racks only six to eight inches from the floor, and a steam table with thick brown buildup and food particles floating in the water were observed; the CDM stated the receiving area mess was from an early delivery and was unaware of the ice machine status.
Failure to Inform Resident in Advance of Care: A resident with impaired communication related to hearing loss was not fully informed in advance about a planned toileting intervention. The DON told the resident staff would take them to the shower room to use the bathroom, but the resident understood this to mean toilet use and instead was placed in a shower chair with a bucket to attempt a BM. Staff confirmed the resident was upset, protested the intervention, and became angry, yelling, and crying afterward.
A resident with an order for a pureed texture diet and nectar thick liquids was served a meal tray that included ground meat, non-pureed vegetables, and regular ice cream. The tray ticket matched the ordered diet, and an aide confirmed the food was not prepared in the required form and that regular ice cream was not appropriate with the nectar thick liquid order.
A resident who needed assistance with ADLs did not receive the adaptive feeding cup or utensil setup listed in the care plan. The resident’s liquid was served in a regular cup, and the meal tray did not match the ticket because the entree and sides were served together instead of in separate bowls. An aide confirmed the ordered adaptive equipment and meal presentation were not provided.
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. A dietary aide stated that there was no dietary supervisor or CDM employed, and the NHA confirmed that the facility did not have a full-time RD or qualified director of food and nutrition services. The issue had also been cited previously.
Food storage and sanitation deficiencies were observed in the main kitchen and on two nursing units. Surveyors found damaged and dirty kitchen surfaces and equipment, expired food items, leftovers without available cool down logs, and improperly dated condiments in a nourishment room. On the University unit, the ice machine serving the second floor had a drainage pipe with no visible air gap to the floor drain, and an LPN confirmed the condiments came from dietary.
The facility failed to obtain informed consent before bedrails were used for two residents and failed to fully assess entrapment risk for five residents with bedrail devices. One resident was found in a room change with a bed already equipped with bilateral assist rails, headboard, and footboard, with no documented assessment or consent in the record. Other residents had physician orders for enabler bars, but the consent documentation was incomplete or absent, and the maintenance director confirmed there was no defined measurement standard for zones 6 and 7 on the bed rail evaluation form.
Arbitration agreements for two residents allowed the facility to control the initial selection of the arbitrator by naming NAF, with a fallback process only if NAF was unavailable. For another resident, the voluntary arbitration agreement lacked an acknowledgement of understanding and did not clearly state the right to rescind within 30 days or the right to refuse signing as a condition of admission or continued care.
Unsafe and Poorly Maintained Resident Environment: The facility failed to maintain a clean, safe, and functional environment on multiple units. Staff described a persistent “phantom” call bell noise at the nurses’ station, while resident areas showed soiled floor mats, sticky hallway spots, damaged flooring, peeling wallpaper, drywall damage, peeling varnish, and HVAC units installed in old casings with sharp metal edges and towels used to block drafts. In the laundry area, staff reported running out of washcloths and using cut towels instead.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found an 8% medication error rate based on 25 opportunities and two errors. An LPN gave Carafate to a resident while she was eating lunch, despite directions to administer it on an empty stomach, and applied Diclofenac gel to another resident's knees without using the dosing card needed to measure the ordered 4-gram dose. The NHA and DON reviewed the concerns with the surveyor.
Menu items were not served as listed for the dining room and two nursing units when bread was omitted from lunch trays despite being on the menu. A resident reported that meal trays often do not contain what they are supposed to, and a dietary aide stated that bread was not served, no dietary supervisor was present, and the bread item was not seen when checking the menu. Bread products were available in the kitchen supply room, but no dinner rolls or bread were plated for the dining room or the affected units.
Food was served at cold temperatures on multiple units after meal carts arrived late and trays were passed immediately. A resident on one unit had puree items and sherbert served cold or melted, another resident’s chicken was cold, and a third resident’s ham was cold; residents and an LPN also reported that meals often arrive cold or are difficult to eat.
Failure to provide written notice before a room change: A resident reported that staff moved her room without explaining why, and she said items were removed from her closets and drawers while she was moved that day. The record showed the resident had lived in the same room for over a year before the move, but there was no documentation that she or her RP received written notice of the reason for the change or that she was offered a chance to see the new room or meet the new roommate.
Failure to Obtain Written Authorization for Resident Funds Management: A resident told the surveyor that the business office held money for him and that he did not receive statements or know the account balance. Records showed he had repeatedly declined facility management of his funds, but the facility still maintained an RFMS account and withdrew monthly payments from his checking account without evidence of written authorization to establish the RFMS account. The DON, NHA, and business office manager confirmed the lack of written authorization.
A resident’s end-of-life directives were not clearly established when the chart showed a change from a prior POLST signed by the resident for CPR and full treatment to a later DNR-LIMITED order and POLST signed by the daughter due to confusion. Although the resident’s MDS showed a BIMS of 15, indicating normal cognition, there was no evidence the facility discussed the code status change with the resident to confirm the resident’s wishes; the NHA and DON confirmed this during interview.
Failure to investigate and report alleged misappropriation of resident property. A resident’s husband reported that staff on one unit took the resident’s wallet with cards and cash and locked it up. An LPN and social worker followed up with unit staff, who denied taking the wallet, but the record showed no formal investigation, no witness statements, and no notification to law enforcement or the state agency. Later, the resident’s purse with money and belongings was found and returned to the husband.
A resident expressed suicidal ideation, stating she wanted a straight razor and would be better off dead. Staff contacted her daughter, who could not calm her, and the resident was placed on q15-minute checks. However, the care plan did not include a comprehensive, person-centered plan to address the suicidal ideation, and the social worker confirmed the finding.
Two residents with documented ROM impairments did not receive the ROM services recommended by therapy. One resident had upper extremity passive ROM and a restorative nursing program recommended, but the record showed no evidence the passive ROM program was provided. Another resident had lower extremity exercises and a functional maintenance ROM program established after PT discharge, but the resident reported nursing had not started the exercises and the DON acknowledged there was no evidence the program was being completed as recommended.
A resident with obstructive sleep apnea did not receive the CPAP therapy recommended by cardiology. The cardiologist asked the facility to obtain the resident’s CPAP because she used it at home, and later strongly recommended CPAP therapy again. The resident said her cardiologist had requested the CPAP three times and that staff never discussed it with her. A note said the recommendation was sent to the NP and that the resident had supposedly refused CPAP in the past, but there was no documentation confirming a discussion or any further follow-up.
Unsecured eye drops were found on the bedside tables of two residents on a nursing unit. One resident stated the facility knew the drops were in the room, and there was no evidence either resident had been evaluated or ordered to self-administer the medication.
Failure to provide routine dental services for two residents with broken teeth and documented dental concerns. One resident had not been seen by the consulting dentist since admission and another had an unknown last dentist visit; both had MDS and care plans noting natural teeth with cavities or broken teeth and no documentation that routine dental services were offered every 6 months as allowed by the State Plan.
Two residents who were assessed as needing staff help with bathing, showering, and personal hygiene did not consistently receive the ADL care reflected in their care plans. One resident’s record showed multiple missed AM and evening care entries and two showers that were documented only as partial baths, while the other resident had repeated missed or incomplete care entries and received only one shower over several weeks. The ADON and DON confirmed the residents’ assessed needs and preferences were not followed as documented.
Failure to honor a resident’s food and beverage preferences. A resident who reported being vegetarian was repeatedly served meat, including ham, Salisbury steak, and bacon, despite dietary dislikes listing pork products and beef products. The resident also reported receiving only water without ice, and the meal ticket did not list any beverages. The NHA stated the dislikes would likely indicate the resident may be vegetarian.
The facility failed to maintain sufficient dietary staffing, resulting in frequent use of Styrofoam containers for resident meals instead of regular dishware. Several residents reported that meals were sometimes or often served on Styrofoam, including all three meals in a day, and that hot meals were less hot and eating from Styrofoam made one resident feel sick. The dietary manager confirmed that Styrofoam was used at least once daily for about two weeks due to staffing shortages and continued less frequently afterward. Review of staffing schedules showed numerous unfilled morning and evening food service worker shifts that were required to meet departmental needs, and these concerns were brought to the NHA and cited under applicable state regulations.
The facility failed to maintain an adequate activity program for all residents after reducing activity department staffing, leading to frequent cancellations and days with no activities. Multiple residents reported that activities had declined, that there were times with no activities available, no alternatives if they did not like the scheduled activity, and weekends when they stayed in bed due to lack of programming. Review of activity calendars showed reduced activities, including no activities on certain Saturdays, only a single church service on some Sundays, and the elimination of evening activities compared to the prior month.
A resident with a history of refusing care and medications was physically restrained by multiple staff members, resulting in bruising and forced administration of Ativan against her will. Staff actions included holding the resident's limbs and mouth shut, with one nurse aide acting outside her scope of practice. The resident's care plan lacked recommended behavioral interventions, and the incident was not reported to the DON or authorities in a timely manner.
Surveyors found that food items in the main kitchen were stored without open or use by dates and many were not properly covered or sealed. These deficiencies were observed in dry storage, bread racks, walk-in freezer, walk-in refrigerator, and production areas, and confirmed with the dietary manager, NHA, and DON.
A resident reported being physically assaulted by another resident, including being struck and having a phone thrown at his face. The incident was reported to both an LPN and the RN in charge, but staff delayed action, telling the resident to wait for the Administrator. No investigation, interviews, or required notifications to authorities were completed, and the Administrator later confirmed the lack of action was due to no witnesses being present.
A resident suffered a leg fracture after an LPN pushed her in a wheelchair without leg rests, causing her foot to get caught. The incident was not reported immediately, and the resident experienced pain and swelling, leading to a hospital admission for surgical intervention.
The facility failed to maintain acceptable nutritional status for four residents, resulting in severe weight loss for one. A resident lost 31.6 pounds (15%) since admission without timely reassessment or intervention from a dietitian. Despite requests for additional nutritional shakes, the facility did not adjust the dietary plan or notify the physician of significant weight changes. Other residents also experienced severe weight loss with delayed assessments and inadequate follow-up.
The facility did not employ a full-time qualified director of food and nutrition services or a full-time qualified dietitian. A part-time registered dietitian worked remotely with some onsite visits during night shifts when no food service operations occurred. The full-time dietary manager lacked necessary certifications and qualifications.
The facility failed to maintain food storage and service equipment according to professional standards. Observations in the main kitchen revealed issues such as a large hole in the wall, debris on the dishwasher, and cracked tiles with pooling water. Dishwashing racks were worn, and the steam table and steamer had buildup. In the [NAME] unit's nourishment room, food items were improperly stored without labels or dates, and the microwave and refrigerator were dirty. These findings were reviewed with the Nursing Home Administrator and DON.
The facility failed to maintain a clean and safe environment, with multiple deficiencies observed across various rooms and units. Issues included an electrical outlet box on the floor, significant dirt buildup, stained privacy curtains, and damaged fixtures. These findings were reviewed with the Nursing Home Administrator and DON.
The facility failed to ensure that nursing staff had documented competencies for enteral tube feeding, catheter care, medication administration, and dressing changes. This deficiency was identified for two RNs and two LPNs, affecting residents with specific medical needs, including those with indwelling catheters, pressure ulcers, and enteral tube feedings.
The facility failed to document and address pharmacy recommendations for several residents. Pharmacy reviews were completed, and recommendations were made to physicians, but there was no evidence of the pharmacist's report or physician's response. This deficiency was confirmed by the Nursing Home Administrator and DON, indicating non-compliance with pharmacy and nursing service regulations.
The facility failed to implement appropriate enhanced barrier precautions for three residents and did not ensure an environment free from potential infection spread due to improper storage of equipment and supplies. Observations revealed unsanitary conditions in residents' bathrooms, the nourishment room, and the laundry area. Residents with wounds, nephrostomy tubes, and Foley catheters were not initially placed on EBP, lacking necessary signage and PPE. These deficiencies were reviewed with the Nursing Home Administrator and Director of Nursing.
A resident was observed with Fluticasone nasal spray on their bedside table, used for allergies, without a physician's order or facility assessment allowing self-administration. The facility did not document the resident's ability to safely self-administer the medication, as required.
A facility failed to establish clear advance directives for a resident, as there were no physician orders or care plans related to the resident's code status. A POLST form indicating DNR status was signed by the resident's responsible party but not by a medical provider. A second POLST form was later provided, signed by the medical provider but not by the resident or their responsible party, indicating confusion and improper documentation.
A facility failed to maintain a resident's ability to eat independently, as documented in MDS assessments. Initially requiring supervision, the resident later needed extensive assistance, with no documented assessment of this decline. The resident also experienced significant weight loss, and Speech Therapy was delayed. The facility lacked documentation of measures to address the decline.
The facility failed to implement physician orders for two residents, leading to deficiencies in care. One resident with a G-tube did not receive necessary water flushes due to a documentation error, while another resident did not have prescribed arm slings available for edema management. These issues were confirmed by the Nursing Home Administrator and Director of Nursing.
A resident with a pressure ulcer on the left foot was found to have neglected foot care, with yellow, thick, and curling toenails and peeling skin. Despite requesting podiatry services three times, the resident had not been scheduled for care due to their initial short-term status. The facility failed to offer or coordinate podiatry services until the resident's status changed to long-term.
The facility failed to maintain or improve the range of motion (ROM) for two residents, leading to deficiencies in their care. One resident, after exhausting therapy benefits, did not receive continued care to maintain ROM, and another resident, despite having a home exercise program, experienced a decline in condition due to lack of a restorative program. Staffing shortages were cited as a reason for not recommending restorative programs.
A facility failed to provide necessary emergency supplies for a resident receiving hemodialysis, who was at risk for bleeding due to anticoagulant medication. The resident, who attended dialysis outside the facility, did not have essential items like sterile gauze or a hemostat in her room, despite having a central line. The deficiency was identified during an observation and interview, and confirmed with facility management.
A facility failed to create and implement an individualized care plan for a resident with dementia. Despite the resident's diagnosis and assessment indicating the need for such a plan, the care plan lacked a personalized approach to address cognitive loss. This deficiency was confirmed with the facility's administration.
A resident experienced a significant delay in receiving medically related social services after the death of her spouse, leading to ongoing depressive symptoms and a decline in condition. Despite expressing feelings of sadness and a lack of appetite, the facility did not provide timely interventions or psychological support, as confirmed by the Nursing Home Administrator.
The facility did not ensure that nurse aides received the required 12 hours of annual in-service training. For two nurse aides, there was either no documented evidence of training completion or insufficient documentation to confirm the training was conducted, leading to a deficiency under personnel policies and procedures.
The facility did not notify the DOH about a dry sprinkler system failure that compromised safety. The issue was known before a repair quote was received, but it was not addressed, leading to a fire alarm activation. The Maintenance Manager confirmed the system was not repaired, although it was functional with a temporary air compressor.
A resident experienced severe health issues, including coughing episodes and unresponsiveness, but the RN failed to complete timely documentation and notify the physician as required. The RN documented the events the following day, despite prior issues with documentation duties.
Food and Nutrition Services Staffing Deficiency
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. During an interview, Employee 6, a certified dietary manager, stated they had been working at the facility only one day a week over the past one to two months to help until the facility obtained a new food and nutrition services director, and that they were employed by another facility owned by the same company. The Nursing Home Administrator stated that the facility's registered dietitian was only employed on an as-needed basis and that the facility did not employ a full-time registered dietitian. The report states that the facility did not employ a full-time registered dietitian or a full-time qualified director of nutrition services.
Housekeeping and Maintenance Deficiencies in Shower Rooms and Breezeway
Penalty
Summary
The facility failed to maintain adequate housekeeping and maintenance services to ensure a clean, comfortable, orderly, and homelike environment on three nursing units and in an outdoor breezeway leading to the central supply room. On the Heirloom unit, the main shower room had a strong musty odor, and a dark black substance was observed lining the grout where the floor met the wall under the shower head, extending several feet along the shower area. An aide stated the bathroom always had the odor and that the black substance had been present for a long time. On the University unit, the main shower room contained a bathtub with black dirt and debris inside, a stained privacy curtain with brown spots, a dirty and ripped shower curtain, scattered and unlabeled toiletries and equipment, a blackened and dirty toilet area, and shower chair seat cushions with multiple open cracks. On the [NAME] unit, the shower stall had black substance along the grout and wall edges, the bathtub contained a wet floor sign, disposable briefs, basins, an electric razor, piping, and an empty shampoo bottle, and the room also had an unbagged toilet riser, a used hairbrush with hair, unlabeled shampoo and conditioner bottles, blackened floor tiles, and marred doors and ceiling access panel. The outdoor breezeway drain had a broken metal cover resting inside the drain hole.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the main kitchen. During an observation on May 6, 2026, a foot pedal garbage can was overflowing with trash and held open vertically by empty food cans and trash. The flooring in the food delivery receiving area was covered in debris, dirt, and black marks, and the certified dietary manager stated the mess was from an early delivery due to rain, although much of the dirt and debris was collected along the wall edges and dried on the floor. The dry storage area was observed to have significantly dirty flooring with black dirt and debris, including lids, wrappers, packs of crackers, and other debris throughout the floor and under food storage shelving units, and the floor was sticky to walk on. A commercial ice dispenser in the dry storage room had dust and debris on it, with parts to the machine lying on top, and the bin contained no ice; the certified dietary manager stated she was not aware when it was last in use or whether it was under repair. Multiple open wire rack shelving units stored food items in the dry storage room, with lower shelves holding food six to eight inches from the floor and no solid barrier between the floor and the food items. The interior compartments of the steam table, observed as staff removed pans of food after lunch service, were coated in thick brown buildup and had multiple particles of food floating in the water.
Failure to Inform Resident in Advance of Care
Penalty
Summary
The facility failed to inform a resident in advance of the care to be furnished. Resident 3 had a care plan for impaired communication related to hearing loss, with an intervention to use a dry erase board for communication. During an interview, the resident was observed to have difficulty hearing even with a hearing aide in place, and questions had to be repeated slowly and loudly for the resident to understand fully. The resident stated they were very upset about what the DON did to them and said they did not understand what was going to happen when the DON told them staff would take them to the shower room to use the bathroom. Resident 3 stated that instead of being taken to the toilet, they were placed in a shower chair with a bucket underneath them and wheeled to the shower room to try to have a bowel movement into the bucket. The resident said they protested multiple times and did not want to be in a chair with a bucket underneath them. The resident also stated that the DON did not write anything down during the conversation and never came back to speak with them afterward. Staff interviews confirmed that the DON directed the resident to be transferred to the shower chair because they needed to have a bowel movement, and staff reported that the resident became very upset, angry, yelling, and crying when returned to the room.
Failure to Provide Ordered Pureed Diet and Thickened Liquids
Penalty
Summary
The facility failed to prepare food in a form that matched a physician-ordered pureed texture diet with nectar thick liquids for one resident. Clinical record review showed an active order for a pureed texture diet with nectar thick liquids. During lunch observation, the resident’s tray contained an entree that appeared as ground meat rather than pureed, along with large pieces of sweet potatoes and peas and diced carrots in regular form, and a container of strawberry ice cream. The tray ticket confirmed the ordered pureed texture diet with nectar thick consistency liquids. A nurse aide confirmed the meat was ground in texture and not pureed, the potatoes and vegetables were not pureed, and that the resident should not have received regular ice cream because of the nectar thick liquid order. The dietary concerns were reviewed with the NHA and DON during interview.
Failure to Provide Ordered Adaptive Eating Equipment and Meal Setup
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who required assistance with ADLs. Resident 5’s care plan identified the need for a spouted sippy cup and red foam built-up handles on spoons to assist with eating and drinking. During observation on May 6, 2026, the resident was in bed with a lunch tray in front of her, but her liquid was served in a regular cup and no sippy cup was observed. Review of the meal ticket also showed the resident was to receive food in separate bowls, but the entree and sides were served together on one plate. An interview with the nurse aide confirmed the resident did not receive the adaptive feeding cup or the food presentation specified in the care plan and meal ticket.
Missing Qualified Food and Nutrition Services Leadership
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. During an interview, a dietary aide stated that the facility did not currently have a dietary supervisor or a certified dietary manager employed. The Nursing Home Administrator later confirmed that the facility did not employ a full-time registered dietitian or a qualified director of food and nutrition services. The report also notes this issue was previously cited on 3/14/25 under 28 Pa. Code 201.18(b)(1)(3) Management.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food and maintain food service equipment in accordance with professional standards in the main kitchen and on two nursing units. In the main kitchen, surveyors observed yellow water-damaged ceiling tiles above the clean dish line that were buckled, broken, and hanging down with broken drywall exposed beneath them, along with an uncovered dirty vent containing dust and cobwebs. The dishwasher room drain had pooled water with grout pieces in it, the three-compartment sink had a continual drip from the hot water faucet, stove knobs had heavy dust and debris behind and between them, and both ovens had brown residue built up inside the glass doors and ovens. Expired apple cider vinegar was found on the spice shelf, and the refrigerator contained multiple containers of leftovers dated the previous day without any available cool down temperature logs. A storage shelf for clean kitchen equipment had a broken plastic cover exposing part of the shelf, and a broken floor tile created a triangular hole in front of the tray line. The refrigerator also contained four quarts of expired Lactaid milk dated February 15, 2026. On the Nittany unit, surveyors observed a zip lock bag of condiments including mayonnaise, ketchup, and mustard in the nourishment room with no date on the bag and no visible expiration or best-before dates on the items inside; an LPN confirmed the condiments were delivered from dietary. On the University unit, the ice machine used as the only ice supply for all residents on the second floor had a white drainage pipe with no visible air gap between the indirect waste pipe and the floor drain. The facility was cited under food storage and sanitation requirements, and the ice machine concern was reviewed with the NHA and DON.
Bedrail consent and entrapment assessments were incomplete
Penalty
Summary
The facility failed to obtain informed consent before bedrails were installed for two residents and failed to assess all potential entrapment risks for five residents who had bedrail use. The facility policy stated that a Bed Rail Education/Consent must be completed before bedrails are placed on a resident’s bed, and that maintenance would confirm consent was completed before installation. The maintenance evaluation form identified seven entrapment zones, but the maintenance director later stated that there was no established measurement or parameter in the facility policy for determining no entrapment risk in zones 6 and 7. Resident 11 was observed in a room with a headboard, footboard, and bilateral assist bedrails after a room change. The resident stated she had recently moved rooms, and the clinical record contained no documented assessment for the need for bedrails, no consent for their use, and no entrapment risk assessment. Facility leadership stated that staff allowed Resident 11 to use the bed already in the room after the transfer, and a maintenance request to remove enabler bars had been submitted several days later but had not been completed at the time of the survey. Resident 8 had an active physician order for bilateral enabler bars, but the Bed Rails Informed Consent for Use was not dated and did not include an acknowledgement or signature. Resident 4 had an active physician order for bilateral enabler bars, Resident 9 had an active physician order for bilateral enabler bars and stated she used them to help move in bed, and Resident 93 had bilateral bedrail assist devices in place even though there was no current physician order until after the surveyor discussed the issue with the facility. Maintenance Bed Rail Evaluations for Residents 4, 8, 9, and 93 indicated that seven zones were checked for entrapment risk, but the maintenance director confirmed there was no defined measurement standard for zones 6 and 7.
Arbitration Agreements Lacked Required Neutrality and Resident Rights Language
Penalty
Summary
The facility's arbitration agreements did not ensure selection of a neutral arbitrator for two residents who had signed agreements. For one resident, the arbitration agreement signed on December 13, 2023 stated that arbitration would be conducted by the National Arbitration Forum (NAF), and if NAF was no longer in existence or unable to conduct the arbitration, a mutually acceptable neutral third-party alternative would be agreed to by the parties. A similar agreement signed by another resident's responsible party on November 22, 2023 also stated that arbitration would be conducted by NAF, with the same fallback language, and both agreements afforded the facility the initial selection of the arbitrator. For a third resident, interview on February 19, 2026 at 11:40 AM revealed he did not remember signing an arbitration agreement. Review of the voluntary arbitration agreement signed by that resident on April 12, 2025 showed that he electronically initialed all paragraphs, but the document did not contain an acknowledgement that he understood the agreement. It also did not explicitly state that he could rescind the agreement within 30 calendar days of signing or that signing was not required as a condition of admission or continued care at the facility.
Unsafe and Poorly Maintained Resident Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services to maintain a clean, safe, and functional environment on three nursing units and in the laundry department. On the University unit, an intermittent audible sound was heard from a wall-mounted call bell device at the nurses’ station, and staff identified it as a “phantom call bell” that had been ongoing for about a year. Employee interviews confirmed there were no resident room call bell lights visible in the hallway, the device had no room number displayed, and the noise continued during multiple observations across two days and throughout the night. Resident areas on the University and Nittany units showed multiple environmental concerns. Resident 7’s floor fall mat had a large amount of various colored debris and spillage on it during repeated observations. On the Nittany unit, hallway flooring outside the main kitchen was observed in disrepair, including a missing floor tile, raised and peeling tiles along the hallway, and a four-foot span of tiles held down with duct tape and masking tape that had peeled away and left adhesive residue. In Resident 109’s and Resident 49’s rooms, heating and cooling units were installed inside old metal casings with sharp metal edges protruding, towels were used to fill gaps and were placed on the casings and windowsills, and drafts were noted. Resident 109’s bedside stand also had a large area of peeling varnish. Resident 84’s bathroom had drywall damage near the mirror and soap dispenser mount, and Resident 49’s bathroom had drywall damage, brown water spots, bubbled paint, and ceiling and wall paint damage. On the Heirloom unit, a large sticky spot remained on the hallway floor across repeated observations. Resident 53’s wall and Resident 121’s wall were both marred next to the doorframe, with wallpaper peeling off the wall. In the laundry area, staff reported the facility often ran out of washcloths and used towels cut to washcloth size instead; this was confirmed by observation of stacks of cut towels in the laundry room and on the unit. The report also noted these concerns were reviewed with the DON and NHA, and cited 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment, along with related state regulations.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent, with surveyors determining an eight percent error rate based on 25 medication opportunities and two medication errors involving Residents 17 and 100. During observation of a medication pass, an LPN administered Carafate 1 gm to Resident 17 while the resident had her lunch tray in front of her and was beginning to eat lunch, even though the medication packaging instructed that it be given on an empty stomach. The LPN stated that trays are normally not this early, and later confirmed that the label directed administration on an empty stomach while the resident was in the process of eating. During the same medication pass, the LPN administered Diclofenac Sodium external gel to Resident 100's bilateral knees by placing a small dollop on gloved fingers and massaging it over the knees. The active physician's order required four grams topically to both knees three times daily, not to exceed 32 grams in 24 hours. The LPN stated she was not aware of the process of using a dosing card to measure an accurate four-gram dose. Surveyors observed that the medication package included a plastic dosing card and a diagram showing the approximate length of gel for two-gram and four-gram doses. The surveyor reviewed both medication error concerns with the NHA and DON.
Menu Items Not Served as Listed
Penalty
Summary
The facility failed to provide menu items as indicated for the dining room and two nursing units, including Heirloom and Nittany, when bread was not served with the lunch meal as listed on the menu. Resident 51 stated in interview that they often do not receive what they are supposed to on their meal tray. The lunch menu for February 19, 2026 listed maple glazed ham, macaroni and cheese, Prince [NAME] vegetable blend, wheat dinner roll, and rainbow sherbet, but during tray line observation no wheat dinner rolls or bread were plated for the dining room or Heirloom unit. On the Nittany unit, Resident 89's tray also had no bread present, and observation of lunch service on the Heirloom unit showed no dinner rolls or bread on any meal trays. At the same time, the kitchen supply room contained three and a half racks of sliced bread, one rack of bread buns, and one rack of hoagie buns. Employee 13, a dietary aide, stated that bread was not served with lunch, that no dietary supervisor was present that day, and that the bread item was not seen when checking the menu for the day.
Food Served at Cold Temperatures on Multiple Units
Penalty
Summary
Food and drink were not served at palatable temperatures on three nursing units, including Heirloom, University, and Nittany, affecting Residents 3, 13, 17, 89, and 93. On the Heirloom unit, the meal cart was scheduled to arrive at 12:00 PM but was observed outside the kitchen at 11:55 AM, and trays did not arrive on the cart until 12:29 PM. Staff then began passing trays immediately, and by 12:42 PM the surveyor tested Resident 3’s tray and found puree ham at 90.4 degrees Fahrenheit, puree mixed vegetables at 92.2 degrees Fahrenheit, puree mac and cheese at 91.4 degrees Fahrenheit, and sherbert melted. Resident 17 stated that her food is delivered cold, and during lunch on the University unit, the surveyor observed trays arriving at 12:15 PM and tested Resident 17’s chicken at 12:18 PM, finding it cold at 107.2 degrees Fahrenheit. On the Nittany unit, lunch trays were delivered at 12:30 PM and staff immediately began passing them. The surveyor tested Resident 93’s tray at 12:35 PM and found the ham cold at 94.5 degrees Fahrenheit. Resident 93 stated that her food is always cold and that it happens every day at every meal. Employee 11 stated that food often arrives cold. Resident 13 stated that the food temperatures are not good, and Resident 89 stated that food often comes cold and that substitutions such as grilled cheese often come cold or very hard and difficult to eat. The concerns regarding food temperatures on the Heirloom, University, and Nittany units were discussed with the Nursing Home Administrator and DON.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to ensure that written notice, including the reason for a room change, was provided before a facility-initiated room move for one resident reviewed for resident choice concerns. Resident 11 stated that her room was changed without explanation, describing that staff came in, removed items from her closets and drawers, and moved her that day. She also stated that she was not told why the move was happening and that she understood English and could understand what staff said to her. Clinical record review showed that Resident 11 had lived in the same room from November 18, 2024, until February 8, 2026, when she was moved to her current room. Nursing documentation noted that staff spoke with the resident about moving rooms and that she agreed, and that her daughter was called and left a message about the move. However, the record contained no evidence that written notice was provided to the resident or her responsible party explaining why the room move was required, and the facility could not provide documentation that she was given the opportunity to see the new location or meet her new roommate. The NHA and DON confirmed during interview that no written documentation had been given.
Failure to Obtain Written Authorization for Resident Funds Management
Penalty
Summary
The facility failed to obtain written authorization to manage personal funds for one resident who had elected to manage his own money. Resident 12 told the surveyor that the business office held money for him, that a cousin deposited a check into that account, and that he did not receive statements or know how much money was in the account. The clinical record showed multiple prior documents in which Resident 12 declined to have the facility manage his funds, including Resident Personal Funds agreements and RFMS Authorization and Agreement to Handle Resident Funds forms signed in 2022 and 2024. The record also included an Authorization Agreement for pre-authorized payments signed by Resident 12 on January 22, 2025, allowing the facility to automatically withdraw a monthly amount not to exceed $2,000 from his checking account. Review of an RFMS statement dated from December 15, 2025, to February 17, 2026, showed monthly payments, care cost debits, interest payment, and a credit adjustment resulting in a $191.88 credit balance. During interviews, the business office manager, DON, and NHA confirmed that Resident 12 authorized the facility to withdraw his personal liability payment from his checking account monthly, but there was no evidence that he provided written authorization to establish an RFMS account.
Failure to Confirm Resident’s Code Status Wishes
Penalty
Summary
The facility failed to establish clear end-of-life directives for one resident. Clinical record review showed an active physician order stating the resident was DNR and DNR-LIMITED with no intubation, while also noting that the treatment plan, including medical treatment, IVF, and ABX, had been discussed with the daughter and a new POLST was completed. The resident’s POLST was signed by the daughter because the resident was confused at that time. However, the resident’s quarterly MDS documented a BIMS score of 15, indicating normal cognition, and the record also contained a previous POLST signed by the resident that indicated CPR and full medical treatment. No evidence was found that the facility discussed the change in code status with the resident to confirm the resident’s wishes. This was confirmed by the NHA and DON during interview, and the resident was unavailable for further interview due to a medical procedure.
Failure to Investigate and Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate and report a potential allegation of misappropriation of resident property involving one resident. Nursing documentation on January 23, 2026, recorded that the resident put her husband on the phone with an LPN, and the husband reported that when the resident was on the Heirloom nursing unit she had a wallet containing cards and $128, and that staff on that unit took the wallet and locked it up. The LPN stated she did not know anything about a wallet but said she would speak with Heirloom staff to see if they had it. A social worker later spoke with the Heirloom nurse, who stated staff did not take anything from the resident and lock it up and that she checked all areas without finding a wallet. The social worker notified the ADON of what the husband and Heirloom staff stated, but the resident’s clinical record contained no investigation into the allegation. During a meeting with the NHA and DON, they stated the resident did not have a wallet. Later nursing documentation noted the resident’s purse with money and belongings had been located and returned to the resident’s husband. The NHA and DON confirmed the findings, and the facility did not complete an investigation, obtain witness statements, notify law enforcement, or notify the Department of Health regarding the husband’s allegation of potential misappropriation of resident property.
Failure to Develop a Care Plan for Suicidal Ideation
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for suicidal ideation for one resident. Clinical record review showed the resident was admitted on September 22, 2025, and on January 30, 2026, nursing documentation noted she was very tearful, stated she was scared and wanted to go home, and said she wanted a straight razor because if she did not do it to herself, "this place will," adding that she would be better off dead. The facility contacted the resident’s daughter, who was unable to calm her, and the resident was placed on every 15-minute checks. Review of the care plan on February 20, 2026, showed no comprehensive, person-centered care plan addressing the resident’s suicidal ideation. An interview with the social worker on February 20, 2026, confirmed these findings.
Failure to Provide Ordered ROM Services
Penalty
Summary
The facility failed to provide services to maintain residents' range of motion (ROM) for two residents reviewed for ROM concerns. Resident 59 was admitted on August 8, 2025, and his most recent quarterly MDS dated January 20, 2026, noted impairment to one side of his upper extremities. His occupational therapy discharge progress note dated September 30, 2025, recommended a restorative nursing program, and a therapy discharge recommendation sheet dated and signed on January 5, 2026, specified an exercise program consisting of bilateral upper extremity passive ROM. The clinical record contained no evidence that Resident 59 received the passive ROM program recommended by therapy. Resident 118 was admitted on November 22, 2023, and her most recent quarterly MDS showed impairment of both lower extremities. She told the surveyor on February 18, 2026, that she had been on PT, which had been discontinued a couple of weeks earlier, and that nursing staff were supposed to complete exercises to both legs but had not started them yet. Her PT discharge summary indicated lower extremity exercises were recommended, a restorative program was not established, and a functional maintenance program was established and trained for ROM, with a prognosis to maintain current functioning described as good with consistent staff follow-through. The DON later stated that the functional maintenance program is completed by nursing staff and would be considered a ROM program, but also acknowledged there was no evidence that Resident 118's ROM program was being completed as recommended.
Failure to Implement Recommended CPAP Therapy
Penalty
Summary
The facility failed to implement CPAP therapy for a resident with obstructive sleep apnea after a cardiologist recommended that the resident receive the machine. A cardiology consult note stated that the cardiologist wanted the facility to obtain the resident’s CPAP because she had been using it at home, and a later cardiology note strongly recommended CPAP therapy for her obstructive sleep apnea. During an interview, the resident stated that her cardiologist had asked for her to have a CPAP machine three times and that staff had never discussed the CPAP machine with her. A progress note documented that the recommendations for CPAP therapy were sent to the nurse practitioner, who reportedly said the resident had refused a CPAP machine in the past. The note also stated that a nurse went to the room to speak with the resident but found her asleep and planned to try again in the morning. There was no further documentation related to CPAP therapy, and the DON later stated that the nurse practitioner told her she had discussed the CPAP machine with the resident and that the resident refused it, but there was no documentation to confirm that discussion occurred.
Unsecured Eye Drops Found in Residents’ Rooms
Penalty
Summary
The facility failed to secure medications on one of four nursing units, involving two residents on the Nittany unit. During observation, an eye dropper container of Refresh Tears was found on Resident 51’s bedside table, and Resident 51 stated the facility was aware the eye drops were in the room. In a separate room, an eye dropper container of Genteal Tears was observed on Resident 13’s bedside table. There was no evidence that either Resident 51 or Resident 13 had been evaluated or ordered to self-administer the eye drops, and the eye drops were stored in the residents’ rooms.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for two residents with documented dental concerns. Resident 30 was admitted on March 18, 2025, and an observation on February 17, 2026, showed several broken teeth. Her admission MDS dated March 24, 2025, indicated she had some natural teeth and was obvious or likely to have cavities or broken teeth, and her care plan initiated April 6, 2025, identified her as at risk for dental or chewing problems related to missing and broken teeth. The clinical record showed she had not been seen by the facility’s consultant dentist since admission and was not seen by a dental hygienist until February 3, 2026, with no documentation that routine dental services were offered every six months as allowed by the State Plan. Resident 2 was admitted on March 23, 2023, and an observation on February 19, 2026, showed some broken teeth. Her annual MDS indicated she had some natural teeth and was obvious or likely to have cavities or broken teeth, and her care plan initiated June 25, 2023, identified her as at risk for dental or chewing problems related to broken teeth. The record showed she was seen by the dental hygiene practitioner on November 14, 2025, but the facility could not provide information on when she was last seen by the consulting dentist, and there was no documentation that routine dental services were offered every six months as allowed by the State Plan.
Failure to Provide and Document ADL Assistance
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living for two dependent residents who were assessed as needing staff help with bathing, showering, and personal hygiene. Resident 11’s MDS showed partial/moderate assistance was needed for bathing, and care plans directed staff to honor her preference for a morning shower and provide supervision for bathing and personal hygiene. Resident 8’s admission MDS showed substantial/maximal assistance was needed for showering/bathing and dependence on staff for personal hygiene, and his care plans directed staff to honor his preference for a morning shower and provide extensive assistance with bathing and limited assistance with personal hygiene. Documentation review for January and February 2026 showed multiple missed or incomplete entries for morning care, evening care, and bathing/showering for both residents. Resident 11 had several occasions where AM and evening care were marked not applicable/not done, and she did not receive showers on two dates when only a partial bath was documented. Resident 8 also had multiple missed or incomplete care entries, did not receive showers on several occasions when documentation was omitted, marked not applicable, or recorded as only a partial bath, and received only one shower over a multi-week period while other entries reflected bed bath, not applicable, or partial bath. The ADON and DON confirmed that the residents’ assessed needs and preferences for ADL care were not followed as documented.
Failure to Honor Resident Food and Beverage Preferences
Penalty
Summary
The facility failed to provide food and drink that accommodated the individualized preferences of one resident, who reported being vegetarian and eating only occasional chicken or turkey. Resident 89 stated that despite telling the facility her preference, she was repeatedly served meat, including ham for breakfast and Salisbury steak at lunch, and later bacon for breakfast. She also reported that she only received water to drink and did not receive ice. Review of the resident’s dietary meal ticket showed pork and pork products and beef products listed as dislikes, with no beverages listed. During interview, the Nursing Home Administrator stated that if the resident’s dislikes included all pork products and beef products, it would likely indicate the resident may be vegetarian. The resident’s food and beverage preferences were not honored.
Insufficient Dietary Staffing Leading to Frequent Use of Styrofoam for Meal Service
Penalty
Summary
The facility failed to provide sufficient staff in the food and nutrition services department, resulting in frequent use of Styrofoam containers for resident meals instead of regular dishware. Multiple residents reported that meals were sometimes or often served on Styrofoam, including for all three meals in a day. One resident stated that food on Styrofoam gets cold quickly, another reported that hot meals were less hot and that this occurred about once a week, and another resident stated that eating off Styrofoam made her feel sick and that she did not like Styrofoam. These resident interviews indicated an ongoing pattern of Styrofoam use for meal service. The dietary manager reported that beginning on December 19, 2025, and lasting for approximately two weeks, Styrofoam was used at least once a day due to frequent staffing shortages in the department, and that it continued to occur less frequently afterward. Review of the food service staff schedule from November 30, 2025, to February 1, 2026, showed numerous open morning and evening food service worker positions on multiple days, indicating that scheduled staffing levels were not met. These open positions were identified as required to meet the needs of the department. The concerns regarding the use of Styrofoam due to insufficient staffing were reviewed with the Nursing Home Administrator, and the deficiency was cited under 28 Pa. Code 201.14(a) Responsibility of licensee and 28 Pa. Code 201.18(b)(3) Management.
Failure to Maintain Adequate Activity Program for All Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the individual needs and interests of all residents, as evidenced by resident interviews and review of activity calendars. One resident reported that activities were often cancelled due to there being only two activity staff, resulting in days with no activities at all. Another resident stated that activities had declined in quality, that there were not always activities to attend, and that there were no alternative options if they did not like the scheduled activity. A third resident reported that activities had been cancelled and that there were now days without any activities, which bothered them. A fourth resident stated they stayed in bed over a recent weekend because there were no activities to attend and expressed that they liked having something to do on weekends. Review of the facility’s activity calendars for December 2025 and January 2026 showed that in January there were no activities scheduled on the first, third, and fifth Saturdays, and the corresponding Sundays listed only a single church service. Further review showed a reduction in the number of activities available in January compared to December, including the removal of evening activities during January. In an interview, the Nursing Home Administrator confirmed that the activity department had recently undergone staffing reductions, which caused the decrease in available activities. These findings were reviewed with the Nursing Home Administrator and the Director of Nursing, and the deficiency was cited under 28 Pa. Code 201.29(a) related to resident rights.
Failure to Prevent Physical Abuse and Forced Medication Administration
Penalty
Summary
A resident with a history of refusing care and medications, as well as exhibiting physical and verbal aggression toward staff, was found to have multiple bruises on her left upper arm. The bruises were discovered after the resident's son reported them to an LPN, who observed three oddly shaped bruises but was unable to measure them due to the resident's refusal. The incident that led to the bruises occurred when staff attempted to administer Ativan to the resident, who resisted and knocked the medication out of the nurse's hand. Multiple staff members were involved in restraining the resident, with one nurse aide placing the pills in the resident's mouth and holding her mouth closed until the medication dissolved, while others held her limbs during the process. Interviews with staff revealed that the nurse aide used excessive physical force, including grabbing the resident's arms and holding her mouth shut, which resulted in the bruising. Staff accounts also indicated that the resident was physically aggressive during the incident, striking and scratching staff members, but the response from staff involved actions outside their scope of practice and the use of physical restraint to administer medication against the resident's will. The nurse aide involved was later heard stating that she made the resident take the pills because she had been scratched. The facility's investigation found that the care plan for the resident did not include specific behavioral interventions suggested by the resident's son, despite her known history of non-compliance and aggressive behaviors. The incident was not reported to the Director of Nursing or other appropriate authorities in a timely manner, as the DON only became aware of the situation two days after it occurred, following the discovery of the bruises. The failure to implement appropriate care plan interventions, prevent physical abuse, and ensure timely reporting contributed to the deficiency.
Failure to Store Food According to Professional Standards
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards in the main kitchen. During an inspection, multiple food items in the dry storage area, bread racks, walk-in freezer, walk-in refrigerator, and production area were found opened without any open or use by dates. Additionally, several items such as mixed vegetables, mushrooms, lemons, and oranges were not covered or sealed. These findings were confirmed during an observation with the dietary manager and later reviewed with the Nursing Home Administrator and Director of Nursing. No information about specific residents or their medical conditions was included in the report.
Failure to Investigate and Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of resident-to-resident physical abuse as required by its own policies and state regulations. A resident reported that another resident entered his room, rummaged through his belongings, physically struck him, and threw his cell phone, causing it to hit him in the face. The resident immediately informed both a licensed practical nurse and the registered nurse in charge, expressing a desire for the police to be called. Despite this, staff told the resident to wait until the Administrator could conduct her own investigation, and no investigation or interviews were conducted with the resident or other involved parties. Text message correspondence between the resident and the Nursing Home Administrator confirmed that, weeks after the incident, no one had spoken to the resident about the event. Interviews with the Administrator, assistant director of nursing, and social services staff confirmed that the facility did not investigate, obtain witness statements, or notify law enforcement or the Department of Health regarding the allegation. The Administrator stated that the lack of witnesses was the reason for not investigating or reporting the incident, which is contrary to facility policy and regulatory requirements.
Neglect Leads to Resident's Leg Fracture
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a fracture of her right leg. The incident occurred when a licensed practical nurse (LPN) pushed the resident in a wheelchair without leg rests, causing her right foot to get caught under the wheelchair. This led to the resident experiencing pain and swelling in her right knee, which was later diagnosed as a fracture of the right femur. The resident was subsequently admitted to the hospital for surgical intervention. The LPN did not report the incident or the resident's change in condition immediately. The resident expressed pain and refused to get out of bed in the days following the incident, prompting a medical provider to be contacted. The LPN's involvement in the injury was only revealed during the facility's investigation, which took place several days after the incident. The lack of immediate reporting and failure to use leg rests contributed to the neglect and subsequent injury of the resident.
Failure to Maintain Nutritional Status Leads to Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for four residents, leading to severe weight loss in one resident. Resident 81 experienced a significant weight loss of 31.6 pounds (15 percent) since admission, with no timely reassessment or intervention from a dietitian. Despite the resident's request for additional nutritional shakes, the facility did not adjust the resident's dietary plan or notify the physician of the significant weight changes. Resident 49 experienced a severe weight loss of 13.2 pounds (10.9 percent) over two months, with no intervention from a nutrition professional until three months later. The resident's provider or responsible party was not informed of the significant change in nutritional status. Similarly, Resident 105 experienced a severe weight loss of 26.7 pounds (15.4 percent) in one month, with delayed assessment by a dietitian and inadequate follow-up on weight monitoring. Resident 108 also experienced a severe weight loss of 13.2 pounds (9.4 percent) in one month, with no timely intervention from a dietitian or notification to the physician. The resident's weight stabilized eventually, but there was a lack of consistent dietary assessment and monitoring. The facility's failure to provide timely assessments and interventions from qualified nutrition professionals resulted in harm to the residents, as evidenced by the severe weight loss and lack of communication with medical providers.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. During an interview, the Administrator revealed that the facility was using a registered dietitian on a part-time basis, who primarily worked remotely with some onsite visits. However, these visits occurred during the night shift when no food service operations were taking place, and residents were likely sleeping. The facility employed a full-time dietary manager, but the Administrator was unsure of this employee's qualifications. A follow-up interview confirmed that the dietary manager was not a certified dietary manager, certified food service manager, did not have a national certification for food service management and safety, and did not hold a degree in food service management.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety. During an observation in the main kitchen, several issues were identified, including a large hole in the wall, dried food splatter on ceiling tiles, and debris on the dishwasher. The dish room had cracked tiles with pooling water and food particles, and the dishwashing racks were worn and broken. Additionally, the steam table and steamer had brown buildup and water dripping onto clean dishes. The stove, plate warming unit, and tilt kettle were also found to be dirty and stained. Further observations revealed that the utensil rack above the cook's table exposed food contact surfaces to airborne particles, and the spatulas were stained. Cake pans had burnt-on buildup, and a garbage can was without a lid. Knife racks and shelves were dusty and dirty, and a portable air conditioning unit was covered in debris. Inside a cooler, containers with diced carrots and hot dogs were found with unclear expiration dates, and a food slicer was dirty. Resident meal service trays and cups were cracked, stained, and contained buildup. In the [NAME] nursing unit's nourishment room, multiple beverage cups and bowls of cereal were improperly stored without labels or dates. The microwave was rusted and had food splatter, and the countertop was stained and broken. The refrigerator was packed with food items without labels or dates, and the freezer contained uncovered items. The ice machine had a loose cover, and the dry storage area had dusty fans. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations across various rooms and units. In Resident 64's room, an electrical outlet box was found lying on the floor with wires extending into a conduit hanging off the wall, and an oxygen concentrator was plugged into this outlet. Additionally, there was a significant buildup of dirt along the baseboard heater. Resident 8's room had marring on the wall behind the bed, and Resident 81's shared bathroom was found with staining, dirty caulking, and a screw preventing a cabinet door from opening. The bathroom also had a missing wall tile and an overflowing garbage can. Further observations revealed that Resident 15's room had privacy curtains with significant staining and brown smears. The [NAME] unit hallway and nourishment room were also in disrepair, with marred walls, dirty floors, rusted and chipped cabinets, and a broken countertop. The nourishment room had a light fixture hanging upside down with exposed wires, and the garbage can was soiled with dried substances. The Nittany Nursing Unit had dust buildup on vents, damaged ceiling areas, and an ice machine covered with a stained cloth pad. Additional deficiencies were noted in Resident 100's room, which had dirt and peeling paint, and Resident 43's room, which had dirt and smeared curtains. Resident 54's room had loose dirt and a tissue with a brown substance on the floor. Resident 82's room had soiled privacy curtains and black buildup on the floor, while Resident 91's room had discolored curtains and a dusty AC filter. These findings were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to provide adequate housekeeping and maintenance services.
Lack of Documented Nursing Competencies
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets necessary for the care and assessment of residents with specific medical needs. This deficiency was identified through a review of facility documentation and staff interviews, which revealed that the facility could not provide evidence of competencies for four employees, including two registered nurses and two licensed practical nurses. These competencies were related to enteral tube feeding, catheter care, medication administration, and dressing changes. The facility had a total of 118 residents receiving medications, eight residents with indwelling catheters, seven residents with pressure ulcers, and three residents with enteral tube feedings. The lack of documented competencies for these employees was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Failure to Document and Address Pharmacy Recommendations
Penalty
Summary
The facility failed to maintain proper documentation and follow-up on pharmacy recommendations for five residents. Clinical record reviews revealed that pharmacy notes indicated completed reviews and recommendations made to physicians for Residents 8, 16, 101, and 108 on various dates. However, there was no evidence of the pharmacist's report of recommendations or a physician's response to these recommendations for the specified dates. This lack of documentation and follow-up was confirmed during an interview with the Nursing Home Administrator and Director of Nursing. The deficiency was identified under the regulation 483.45(c)(4) Pharmacy review, which had been previously cited on April 26, 2024. The facility's failure to maintain pharmacy recommendations or evidence of physician responses indicates a lapse in the required pharmacy services and nursing services as per the 28 Pa. Code 211.9 (d)(k) and 28 Pa. Code 211.12(d)(3)(5). This deficiency highlights the facility's non-compliance with established guidelines for drug regimen reviews and the necessary communication between pharmacists and physicians.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to implement appropriate enhanced barrier precautions (EBP) for three residents and did not ensure an environment free from potential infection spread due to improper storage of resident equipment and supplies. Observations revealed that raised toilet seats were placed directly on the floor in residents' bathrooms, and the nourishment room contained a rusted cabinet with various items, including protective gowns and personal hygiene items, stored in unsanitary conditions. Additionally, the facility's laundry area was found to have linens stacked directly on the ground, a broken window, and significant dust and debris accumulation, indicating poor infection control practices. Resident 72, who had wounds on the lower extremities and a history of MRSA, was not on EBP as required, with no PPE or signage indicating precautions in place. Similarly, Resident 40, with a nephrostomy tube, and Resident 325, with a Foley catheter, were not initially placed on EBP, lacking necessary signage and PPE. These residents' care plans included EBP interventions, but there was no evidence of implementation until after the survey observations. The facility's failure to adhere to infection prevention protocols was further highlighted by the condition of the laundry area, where linens were exposed to the environment, and equipment was covered in dust and debris. These deficiencies were reviewed with the Nursing Home Administrator and Director of Nursing, indicating a systemic issue in maintaining infection control standards across the facility.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that a resident's ability to self-administer medications was determined. During an observation, a resident was found in bed with Fluticasone nasal spray on the bedside table, which the resident used for allergies. A physician's order dated February 22, 2025, prescribed the nasal spray for allergic rhinitis, but there was no order or documentation indicating that the resident was assessed and approved to self-administer the medication. This deficiency was discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Establish Clear Advance Directives for a Resident
Penalty
Summary
The facility failed to establish clear advance directives for a resident, identified as Resident 323. Upon review, it was found that there were no current physician orders or care plans related to the resident's code status, which indicates instructions for healthcare personnel in case of cardiac or respiratory arrest. A POLST form, which should direct medical staff on life-sustaining treatment, was located in the POLST binder but was only signed by the resident's responsible party and not by a medical provider, indicating a DNR status. This discrepancy was confirmed by a licensed practical nurse. Subsequently, a second POLST form was provided by the facility, signed by the medical provider but not by the resident or their responsible party, suggesting confusion and lack of proper documentation regarding the resident's advance directives.
Failure to Address Decline in Resident's Eating Ability
Penalty
Summary
The facility failed to maintain or improve a resident's ability to perform activities of daily living, specifically eating, without a documented medical reason for the decline. A clinical record review for a resident revealed that an MDS assessment initially indicated the resident required supervision with setup help only for eating. However, a subsequent MDS assessment showed the resident required extensive assistance from one staff member for eating. There was no documented evidence that the facility identified or assessed the resident's decline in eating ability. Additionally, the resident experienced a significant weight loss of 27.10 pounds, equating to a 15.65 percent severe weight loss over three months. Speech Therapy did not assess the resident until several months after the decline began. The facility was unable to provide documentation of any measures taken to address the resident's decline in eating ability.
Failure to Implement Physician Orders for Residents
Penalty
Summary
The facility failed to implement physician orders for two residents, leading to deficiencies in care. Resident 115, who was admitted with a gastrostomy tube (G-tube), reported that the tube had not been flushed since feedings were stopped, despite having an active physician's order for water flushes. The clinical record review confirmed that the order for water flushes was not documented in the resident's medication or treatment administration records, resulting in the resident not receiving the necessary flushes to maintain the tube's patency. Resident 104 had a physician's order for the use of arm slings to manage edema by keeping the arms elevated. However, during an interview, the resident reported not having a sling available in the room. The treatment administration record indicated that the sling was documented as applied on several dates, but there were notes indicating the sling was awaited on other dates. This discrepancy suggests a miscommunication between nursing staff and the physician, leading to the resident not receiving the prescribed treatment. The deficiencies were reviewed with the Nursing Home Administrator and Director of Nursing, who confirmed the issues with the orders for both residents. The failure to implement these physician orders resulted in a lack of appropriate care for the residents, as evidenced by the absence of necessary treatments and interventions.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to provide proper foot care for a resident, identified as Resident 81, who was observed with yellow, extremely thick toenails on the left foot during a pressure ulcer dressing change. The toenails were described as being one-half inch in depth, raised, and curling upward with a fungal appearance, while the skin on the toes was scaled and peeling. The resident reported having requested to see a podiatrist three times without success. The Director of Nursing explained that the resident was not scheduled for routine podiatry services because they were initially considered short-term, and only long-term residents were added for such services. The resident had recently changed to long-term status, which would now allow them to be added for routine services. A nursing note indicated that the resident's family wanted to schedule the podiatry appointment themselves to ensure transportation. However, there was no evidence that the facility offered or assisted in coordinating podiatry services prior to this note.
Failure to Maintain Residents' Range of Motion
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) for two residents, leading to deficiencies in their care. Resident 101, admitted in November 2023, was assessed with impaired ROM in his bilateral lower extremities. After exhausting his therapy benefits, Resident 101 was discharged from physical therapy in January 2025 with a positive response to passive techniques and a good prognosis for maintaining his function with staff assistance. However, there was no documentation of continued care from staff to maintain his ROM post-therapy. The physical therapist did not recommend a restorative nursing program due to reported staffing shortages, which contributed to the lack of follow-up care. Similarly, Resident 25, admitted in March 2019, was discharged from physical therapy in September 2024 with a home exercise program and an excellent prognosis with consistent staff support. Despite this, no restorative program was established, and the resident reported a decline in her condition, specifically in her left knee, since discontinuing therapy. The physical therapist again cited staffing shortages as the reason for not recommending a restorative program. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed these findings, indicating a failure to prevent further decline in the residents' ROM.
Failure to Provide Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis. During an interview and observation, it was noted that the resident, who attended dialysis outside the facility three times a week, did not have any emergency supplies in her room. This included essential items such as sterile gauze, a hemostat, a needleless connector, or tape, which are crucial for managing potential bleeding from the resident's central line. The resident confirmed that she had an emergency kit at home but had not received one since her admission to the facility. The clinical record review revealed that the resident had a left chest tunnel catheter for dialysis and was at risk for bleeding due to anticoagulant medication. The care plan indicated that in the event of bleeding, pressure should be applied, and emergency services contacted if necessary. Despite these risks, the facility did not provide the necessary emergency supplies until after the deficiency was identified. This oversight was confirmed during a review with the Nursing Home Administrator and Director of Nursing.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. The clinical record review revealed that the resident was admitted with a diagnosis of dementia, which affects memory, language, problem-solving, and other cognitive abilities. Despite the facility's assessment indicating the need for a care plan to address dementia and cognitive loss, the review of the resident's care plan showed no evidence of an individualized approach to meet these needs. This deficiency was confirmed during a review with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Timely Social Services for Grieving Resident
Penalty
Summary
The facility failed to provide medically related social services to a resident who was grieving the loss of her spouse. The clinical record review revealed that the resident was informed of her husband's death and exhibited signs of depression, such as crying and a lack of appetite. Despite these indicators, there was a significant delay in the provision of social services, with no documented interventions for 11 days following the notification of her spouse's death. During this period, the resident expressed feelings of sadness and a desire to die, although she later clarified that she did not want to die but was not feeling well. Interviews with the resident and her family indicated ongoing depressive symptoms and a decline in her condition, with family members expressing concern that she was giving up due to her grief. The facility's failure to provide timely and adequate social services support during the grieving process was acknowledged by the Nursing Home Administrator, who confirmed the lack of evidence for interventions to support the resident's emotional needs and offer psychological services. This deficiency highlights the facility's inability to meet the resident's needs during a critical time of emotional distress.
Failure to Ensure Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of in-service training annually, as mandated by regulations. During a meeting with the Nursing Home Administrator and Director of Nursing, the surveyor requested training records for two nurse aides, Employees 16 and 17. It was confirmed through an interview with the Director of Nursing that there was no documented evidence of Employee 16 receiving the necessary training hours in the past year. Although Employee 17's records indicated completion of 27.5 hours of training, the documentation only showed that a packet of information was given to Employee 17 for review, with no further evidence of actual training completion. This lack of proper documentation and assurance of training completion led to the deficiency. The deficiency was identified under 28 Pa. Code 201.19 (7) concerning personnel policies and procedures, highlighting the facility's failure to comply with the required in-service training for nurse aides.
Failure to Report Sprinkler System Failure to DOH
Penalty
Summary
The facility failed to notify the Department of Health (DOH) about an event that compromised quality assurance and patient safety. The issue involved the dry sprinkler system, which serves the entire facility. The problem was known before a repair quote was received on December 24, 2024, but the facility did not address the issue identified in the quote. This inaction led to the failure of the dry sprinkler system on January 27, 2025, which caused a fire alarm activation. As of February 6, 2025, these events had not been reported to the DOH. During an exit conference on February 5, 2025, the Maintenance Manager confirmed that the cause of the dry sprinkler system failure had not been repaired at the time of the survey. Although the dry system was operational with the use of a temporary air compressor, the failure to report the incident to the DOH was a significant oversight. This deficiency was noted under the NFPA 101 General Requirements, specifically referencing Title 28, Health and Safety, Part IV. Health Facilities § 51.3. Notification. (e)(f).
Plan Of Correction
The facility had identified an issue with the dry system prior to this event. Staff have been educated on events that need to be reported to the department of health and will do so in a timely manner. Two vendor quotes were obtained for the repairs. The dry system was functioning fully until the permanent repairs can be completed. The vendor is scheduled to be onsite March 3, 2025, to complete the permanent repairs to the dry system.
Failure to Ensure Timely and Accurate Documentation
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for a resident who was admitted on June 12, 2024. On November 12, 2024, the resident experienced a series of health issues, including a mild coughing episode during lunch, a significant drop in oxygen saturation, and a severe coughing episode during dinner, which led to unresponsiveness and eventually cessation of breathing. Despite these critical events, the registered nurse did not complete the required Change in Condition Tool, and there was no documentation that the resident's physician was notified, although the CRNP later indicated that she was informed and had given instructions for monitoring and further actions. The registered nurse, identified as Employee 1, did not document her assessments and actions until the following day, November 13, 2024. Her documentation noted that she was informed of the resident's condition changes and had instructed the application of oxygen. However, her records were not completed in a timely manner, as expected by the facility's policy. Employee 1 had a prior record of failing to complete documentation and communication duties, as noted in her personnel file. The facility's administration confirmed these findings and acknowledged the expectation for timely documentation to ensure continuity of care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 98 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near State College
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Foxdale Village | 1.1 mi | ★★★★★ | 0 | 0 |
| Juniper Village At Brookline-rehabilitation And Sk | 1.6 mi | ★★★★★ | 2 | 0 |
| Village At Penn State, The | 3.3 mi | ★★★★★ | 10 | 0 |
| Centre Care Rehabilitation And Wellness Services | 5.7 mi | ★★★★★ | 5 | 0 |
| Valley View Haven, Inc | 13.8 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Embassy Of Hearthside.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.