Every finding on record at Community at Rockhill, The

Based on clinical record review and staff interview, it was determined the facility failed to provide copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for four out of four residents who were transferred out of the facility (Residents 6, 8, 53, and 55).Clinical record review revealed that Resident 6 was transferred to the hospital on April 11, 2025, and May 17, 2025, after significant changes in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 8 was transferred to the hospital on April 27, 2025, and May 18, 2025, after significant changes in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 53 was transferred to the hospital on June 25, 2025, after significant changes in condition. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 55 was discharged from the facility to his home on July 19, 2025. There was no documented evidence that the facility sent copies of the written discharge or transfer notices to a representative of the Office of the State Long-Term Care Ombudsman. In an interview on August 14, 2025, at 9:29 a.m., the Director of Nursing confirmed that the written copies of the discharge or transfer notices were not sent to the Office of the State Long-Term Care Ombudsman. 28 Pa. Code 201.14(a) Responsibility of licensee.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for two of 23 sampled residents. (5, 12) Findings include: Clinical record revealed that Resident 5 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 31, 2019 indicated that the resident utilized a physical restraint on a daily basis. Review of nursing documentation revealed that R5 did not utilize any restraint. Clinical record revealed that Resident 12 had [DIAGNOSES REDACTED]. The MDS assessment dated (MONTH) 21, 2019 indicated that the resident utilized a physical restraint on a daily basis. Review of nursing documentation revealed that R12 did not utilize any restraint. In an interview on (MONTH) 3, 2019 at 10:30 a.m., the Director of Nursing stated that the use of the physical restraint was coded inaccurately on both assessments. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review and staff interview, it was determined that the facility failed to follow physician orders [REDACTED]. (Resident 28) Findings include: Clinical record review revealed that Resident 28 was admitted to the facility on (MONTH) 14, (YEAR), and had [DIAGNOSES REDACTED]. On (MONTH) 28, 2019, a physician ordered for staff to check Resident 28's blood pressure twice daily, every evening shift due to the use of an antidepressant medication. Review of Resident 28's, Medication Administration Record [REDACTED]. In an interview on (MONTH) 5, 2019, at 12:15 p.m., the Assistant Director of Nursing confirmed that the resident's blood pressure was not obtained on (MONTH) 11 and (MONTH) 12, 2019, as ordered by the physician. 28. Pa. Code 211.12(d)(1)(5) Nursing Services. Previously cited 6/15/18

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were reviewed and acted upon by the attending physician for one of 23 sampled residents. (Resident 19) Findings include: Clinical record review revealed that Resident 19 had [DIAGNOSES REDACTED]. A monthly pharmacy review completed on (MONTH) 11, 2019, included recommendations to evaluate the current dose of of an anti-anxiety medication and consider a gradual taper to ensure that the resident was receiving the lowest effective dose. On (MONTH) 16, 2019, a Certified Registered Nurse Practitioner approved the orders to taper the anti-anxiety medication. There was no documentation in the clincal record to verify that the attending physician acknowledged and acted upon the recommendation. In an interview on (MONTH) 30, 2019, at 12:15 p.m., the Assistant Director of Nursing confirmed that the physician had not reviewed the pharmacist recommendation. 28. Pa. Code 211.12(d)(1) Nursing Services. Previously cited (MONTH) 18, (YEAR) 28. Pa. Code 211.2(a)(d)(1)(2) Physician Services.

Based on observation, review of sanitation logs and staff interview, it was determined that the facility failed to ensure that dish machines met required temperatures and chemical sanitation levels to sanitize dishware and utensils in two of three kitchens. (Main kitchen, Arbor nursing unit) Findings include: On (MONTH) 24, (YEAR), at 9:44 a.m. observation in the kitchen in the Arbor dining room revealed staff completing clean up from breakfast. Dietary Employee 1 stated that dishes and utensils had already been sanitized from the meal by utilizing the dish machine in Arbor kitchen. A review of the cold water temperature dish machine sanitation log for the Arbor dining revealed that staff was to test the sanitizer level of the dish machine prior to use to ensure that the chemical sanitizer was reaching the appropriate level (100 parts per million (ppm)) to adequately sanitize dishware. Staff had failed to document on the sanitation log that the chemical sanitizer was checked prior to use on the morning of (MONTH) 24, (YEAR). When questioned, Dietary Employee 1 stated that she had not checked the chemical sanitizing level prior to use of the dishmachine on that morning. A check of the sanitizing level at that time in the presence of the Dietary Manager revealed a chemical sanitizing level of 10 ppm, not the required 100 ppm. A second check of the level revealed the same results. The Dietary Manager stated that staff should of checked and recorded the sanitizing level of the dish machine prior to use. Review of sanitation logs for the dish machine located in the main kitchen on (MONTH) 24, (YEAR), at 9:17 a.m. with the Dietary Manager present revealed that staff was to check the sanitizing hot water temperature at final rinse prior to dishmachine use. Staff was to document the temperature of the final rinse temperature to insure dishware was adequately sanitized. A temperature of 180 degrees Fahrenheit was required to sanitize dishware. A review of the sanitation log for the month of (MONTH) (YEAR) revealed that staff documented at least 30 times that the dishmachine did not reach 180 degrees Fahrenheit to adequately sanitize dishware. Inadequate rinse temperatures were recorded as low as 164 degrees Fahrenheit. The Dietary Manager reported that staff had failed to report the inadequate rinse temperatures to a dietary supervisor for correction. 28 Pa. Code 201.18(b)(1) Management. Previously cited 5/24/17

Based on observation, review of food temperature logs, policy review and staff interview, it was determined that the facility failed to monitor food and beverage temperatures to ensure that food and drink served to residents was at palatable, safe and appetizing temperatures in one of two dining rooms. (Arbor) Findings include: On (MONTH) 24, (YEAR), at 9:50 a.m. food and beverage temperature logs were requested from the Dietary Manager at the completion of breakfast in the Arbor dining room. The temperature log had not been completed for the food and beverages served to residents that morning. Dietary Employee 1 reported that the food and beverage temperatures for that morning service had not been taken. A review of the log and Food Temperatures, Sanitation and Infection Control policy dated (MONTH) (YEAR), directed staff to record the temperatures of all food at the tray line and/or point of service dining areas. Staff was to record temperatures on the food service log. The Food Service Director confirmed that the food and beverage temperatures had not been taken and recorded for breakfast in the Arbor dining room that morning. 28 Pa. Code 201.18(b)(1) Management. Previously cited 5/24/17.

Based on clinical record review, observation, incident and accident review and staff interview, it was determined that the facility failed to assess bed rail alternatives, review the risks and benefits of bed rail use with the resident and/or resident representative and obtain consent for the use of bed rails for two of 18 sampled residents. (Residents 5, 40) Findings include: Clinical record review revealed that Resident 5 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated (MONTH) 1, (YEAR), identified that the resident had long and short term memory impairment, moderately impaired decision making and that the resident had fallen since being admitted to the facility. Incident/accident review revealed that on (MONTH) 16, (YEAR), Resident 5 had a fall from bed. The facility's investigation revealed that at the time of the fall the resident's bed rail was difficult to lock and may have contributed to the fall. The resident was observed in bed on (MONTH) 24, (YEAR), at 11:25 a.m. and 12:17 p.m. with two quarter rails in the up position at the top of the bed. There was no documented evidence to support that the facility assessed alternatives to bed rails prior to installation and that the resident or resident's representative was educated on the risks (e.g. entrapment) and benefits of utilizing the bed rails and gave consent for their use. Clinical record review revealed that Resident 40 was admitted to the facility on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. On all days of the survey, the resident's bed was observed with a small bed rail near the head of the bed. There was no documented evidence to support that the facility assessed alternatives to bed rails prior to installation and that the resident or resident's representative was educated on the risks and benefits of utilizing the bed rails and gave consent for their use. In an interview on (MONTH) 26, (YEAR), at 10:41 a.m. the Director of Nursing stated that the facility had not been assessing residents for bed rail alternatives or educating residents or resident's representatives on bed rail usage or obtaining consent for use. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/24/17

Based on resident council interview and staff interview, it was determined that the facility failed to ensure that all the residents had the right to receive and send mail on regular postal delivery days. Findings include: On (MONTH) 25, (YEAR), at 10:30 a.m. a meeting was held with four members of the resident council (Residents 1, 7, 22, 26). During the meeting the residents reported that their mail was not delivered on regular postal delivery days. They reported that mail was not delivered on Mondays. In an interview on (MONTH) 25, (YEAR), at 11:37 a.m. the Volunteer Coordinator Director stated that her department was responsible for the delivery of mail to residents. She reported that mail delivered by the post office on Saturdays was not delivered to residents unit the following Tuesday. She reported that their was no mail delivery to residents on Mondays as there were no volunteers assigned to deliver mail on that day of the week. 28 Pa. Code 201.29(j) Resident rights. Previously cited 5/24/17

Based on clinical record review and observation, it was determined that the facility failed to provide assistance to maintain grooming and personal hygiene for one of 13 sampled residents. (Resident R41) Findings include: Clinical record review revealed that Resident R41 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment and required extensive assistance from staff for most activities of daily living including hygiene. The current plan of care revealed a problem area of an activities of daily living deficit related to [MEDICAL CONDITION] and dementia. An intervention was for staff to provide extensive assistance to the resident for personal hygiene. Observation on May 22, 2017, at 9:05 p.m., and again on May 23, 2017, at 9:45 a.m., revealed that the resident was dressed and seated in his wheelchair in the activity/dining room area with several other residents and staff members in the vicinity. The resident's hair had not been combed, his fingernails were not trimmed and the nail beds were dirty. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 4/29/16

Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for one of 15 sampled residents. (Resident R12) Findings include: Clinical record review revealed that Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On April 5, 2017, the physician ordered for the resident to be weighed weekly. Staff failed to follow the physician's order to weigh the resident weekly as there was no weight obtained on April 13, 2017. In an interview on May 23, 2017, at 12:45 p.m. the Assistant Director of Nursing confirmed that the resident was not weighed weekly per physician's order. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 4/29/16

Based on review of facility policy, group interview and review of resident council meeting minutes, it was determined that the facility failed to ensure that an on-going grievance was resolved for two of four alert and oriented residents. (Residents R50, R51) Findings include: Review of the facility's policy entitled Grievance policy-Resident Rights, dated March 2017, revealed that the facility was to make prompt efforts to ensure the resolution of all grievances. During a group interview on May 22, 2017, at 10:30 a.m., two of four alert and oriented residents stated that there had been an on-going issue related to call bell response. Specifically, the residents stated that it took too long for staff to respond to call bells and that the staff often turned the call bell light off without addressing the residents' needs. Review of the resident council meeting minutes for October 25, 2016, and January 24, 2017, revealed that the residents had reported the call bell issue and that it was not getting any better. The resident council meeting minutes dated February 28, 2017, revealed that the resident's had expressed a concern that staff turn the call lights off and the staff tend to walk out of the room before addressing the residents' needs. There was no documented evidence that the facility had made prompt efforts to ensure that the aforementioned concerns were resolved in a timely manner. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review, policy review and staff interview, it was determined that the facility failed to incorporate the resident's choice to not be resuscitated into the treatment plan and did not obtain a physician's order consistent with the resident's documented wishes in the event of [MEDICAL CONDITION] for one of 15 sampled residents. (Resident R12) Findings include: Review of the facility policy Advance Directive/ Living Will/ Code Status, dated [DATE], revealed that the physician was to be notified of the presence of an advance directive and the physician would then have a discussion with the resident regarding the resident's choices and the physician would then document the resident code status. Clinical record review revealed that Resident R12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital records revealed Resident R12 had a do not resuscitate (DNR) order while in the hospital prior to admission. Review of the advance directive on the clinical record revealed that the resident did not want to be resuscitated in the event of [MEDICAL CONDITION]. There was no documented evidence that the physician or any staff discussed the code status with the resident upon admission. There was no physician order indicating the resident's choice to not be resuscitated. There was however, under code status in the electronic record, documentation indicating that the resident was a full code status ( meaning that staff were to perform CPR in the event of [MEDICAL CONDITION]). The resident remained a full code from admission through [DATE], despite her documented wishes to not be resuscitated in the event of [MEDICAL CONDITION]. In an interview on [DATE], at 12:45 p.m. the Assistant Director of Nursing confirmed that the resident's request for DNR status had not been followed through per policy and that the clinical record full code status was not reflective of the resident's choice for DNR status. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(a) Resident rights.

Based on clinical record review, resident and staff interview, it was determined that the facility failed to schedule care to accommodate preferences for four of 15 sampled residents. (Residents R 12, R19, R37, R51) Findings include: Clinical record review revealed that Resident R12 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented and required extensive assistance with hygiene/bathing. The current plan of care revealed a problem area of activities of daily living (ADL) deficit related to [MEDICAL CONDITION]. An intervention was to provide assistance to the resident to complete personal hygiene. Review of the ADL bathing records revealed that there was no documented evidence that the resident was offered a shower on April 14, 2017. Clinical record review revealed that Resident R19 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented and required extensive assistance with hygiene/bathing. The current plan of care revealed a problem area of activities of daily living (ADL) deficit related to [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. An intervention was to provide extensive assistance to the resident to complete personal hygiene. Review of the ADL bathing records revealed that there was no documented evidence that the resident was offered a shower on April 27, 2017, May 11 and May 18, 2017. Clinical record review revealed that Resident R37 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was alert and oriented and required extensive assistance with hygiene/bathing. The current plan of care revealed a problem area of activities of daily living (ADL) deficit related to [MEDICAL CONDITION]. An intervention was to provide extensive assistance to the resident to complete personal hygiene. Review of the ADL bathing records revealed that the resident was offered a shower on May 5, 2017, however; there was no documented evidence that the resident was offered a weekly shower again through May 22, 2017. Clinical record review revealed that Resident R51 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident was alert and oriented and required extensive assistance with hygiene/bathing. The current plan of care revealed problem area of ADL deficit related to impaired balance and [MEDICAL CONDITION]. An intervention was for the resident to perform ADL tasks with assistance of one person. In an interview on May 22, 2017, at 10:30 a.m., the resident expressed a concern that he does not receive his showers on a weekly basis as per his preference. He stated that he usually received a shower on a Saturday; however, the times vary and the activity did not always occur. Review of the ADL bathing records revealed that there was no documented evidence that the resident received a shower as scheduled on Saturday April 29, 2017. In an interview on May 23, 2017, at 1:00 p.m., the Assistant Director of Nursing confirmed that residents were to be offered a shower once weekly and that there was no documented evidence that the aforementioned residents received showers as per their preference. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on clinical record review, staff interview, and observation, it was determined that the facility failed to ensure that a hand splint was provided to prevent further limitations in range of motion for one of two sampled residents with limitation in range of motion. (Resident R60) Findings include: Clinical record review revealed that Resident R60 had [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set assessment, dated March 8, 2016, the resident was dependent on staff for activities of daily living and had limited range of motion to her arm on one side. The most recent care plan, dated February 3, 2016, indicated that the resident had a decrease in range of motion of the left side and required a splint on the left hand at all times. On March 8, 2016, the physician ordered that staff apply a left hand splint at all times, except for care and exercise. On April 28, 2016, at 9:05 a.m., the resident was observed in bed and NA1 had just finished feeding the resident breakfast. The left hand splint was not on the resident at that time. NA1 returned to Resident R60's room and provided the resident with morning care and exited the room at 9:40 a.m. The resident's splint was not on the resident but was in the bedside cabinet drawer. At 10:25 a.m., NA2 (the restorative aide) was observed providing hygienic care and exercise to the resident's left hand. At that time, NA2 stated that the resident's splint was not on when she entered the room and that she found it in the resident's drawer. NA2 confirmed that the splint was scheduled to be on at all times, removed for hygienic hand care and exercise which only she provided. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/20/15 28 Pa. Code 211.12(d)(1) Nursing services.

Based on facility policy review, staff interview and observation, it was determined that the facility failed to ensure that respiratory equipment was properly cleansed and stored to prevent the spread of infection on one of two units. (Keystone) Findings include: Review of the facility policy entitled Nebulizer Care and Use of Nebulizers and Oxygen Concentrators, dated April 13, 2016, revealed that staff was to rinse the nebulizer mask after use, air dry, and place in a plastic bag after use. The policy further indicated that that oxygen nasal cannula's and masks were to be stored in plastic bags when not in use. During observation of the medication pass on April 27, 2016, at 9:35 a.m., LPN1 adminstered a medicated nebulizer treatment to Resident R72. At the conclusion of the treatment, the nurse removed the mask and nebulizer from the resident and placed it intact in the plastic bag. The nurse did not rinse any nebulizer equipment (chamber and mask) and allow to air dry. During observation of the medication pass on April 27, 2016, at 1:05 p.m., LPN2 adminstered a medicated nebulizer treatment to Resident R64. At the conclusion of the treatment, the nurse removed the mask and nebulizer from the resident, disconnected the mask from the nebulizer chamber, took a paper towel and wiped out the nebulizer chamber, reconnected the equipment and placed it in a plastic bag. The nurse did not rinse any of the nebulizer equipment and allow it to air dry. On April 26, 2016, at 9:10 a.m., at 1:30 p.m., and on April 27, 2016, at 8:45 a.m., Resident R64's nasal cannula was observed draped across the back of the wheelchair. On April 26, 2016, at 9:30 a.m., and at 12:10 p.m., Resident R55's nasal cannula was draped across the resident's bed. The oxygen concentrator was turned on during the observations and the resident was not in the room at the time. In an interview conducted on April 28, 2016, at 9:50 a.m., the Director of Nursing confirmed that the nebulizer mask and oxygen tubing were not handled in accordance with facility policy. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 5/20/15

Based on review of manufacturer's specifications, observation and staff interview, it was determined that the facility failed to ensure that thickened beverages were stored according to acceptable standards on three of three satellite kitchens that were located on the nursing units. (Arbor, Trellis, and Garden nursing units) Findings include: Review of the manufacturer's specifications revealed that containers of thickened juice were to be discarded if not used in five days from the date opened, which staff was to record on the product. Observation on May 17, 2015, at 9:41 a.m., during an environmental tour of the satellite kitchens on all three nursing units revealed that there were a total of eight containers of thickened juices that had been opened but did not have the date that they had been opened recorded on the product. In an interview on May 19, 2015, at 9:40 a.m., the Administrator confirmed that staff was to record the date on the containers of all thickened juices once they were opened and that the containers were to be discarded per manufacturer's specifications.

Based on clinical record review and observation it was determined that the facility failed to implement care planned interventions for one of 17 sampled residents. (Resident R56) Findings include: Clinical record review revealed that Resident R56 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and required assistance of one for eating her meals. Review of the current care plan revealed that the resident had an altered nutritional status due to impaired swallowing (dysphagia) and was at risk for aspiration. Current care plan interventions were for staff to provide set-up, cueing and assistance with meals and for staff to place a non-skid mat (Dycem) under her plate to prevent sliding. Observation on May 18, 2015, revealed that the resident was in the Arbor dining room. The resident was served her meal at 12:48 p.m.; however, the resident was not eating her meal and she did not receive assistance or cueing from staff until 1:05 p.m.. In addition, observations on May 18, 2015, at 12:28 p.m., and again on May 19, 2015, at 9:00 a.m., and 12:47 p.m., revealed that the resident was in the Arbor dining room and had been served her meal without the Dycem under her plate. 483.20(k)(ii) Comprehensive Care Plans Previously cited 6/20/14 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/29/14, 6/20/14

Based on a group interview and review of resident council minutes, it was determined that the facility failed to ensure that an on-going grievance was resolved for four of five alert and oriented residents who attended the group meeting. (Residents R7, R34, R35. R36) Findings include: During a group interview on May 18, 2015, at 9:30 a.m., four of five alert and oriented residents stated that there had been an on-going issue related to food service in the Arbor dining room. Specifically, the residents stated that they continued to be dissatisfied with the amount of time that they had to wait to receive their meals in this dining room. Review of the resident council meeting minutes revealed that at the March 24, 2015, and April 28, 2015, meetings, the residents had mentioned this concern regarding the long wait to be served their food. In an interview on May 19, 2015, at 9:42 a.m., the Administrator stated that there was no documented evidence that the aforementioned on-going grievance had been resolved in a timely manner. 28 Pa. Code 201.29(j) Resident rights.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate clinical record documentation for one of four sampled residents. (Resident CR1) Findings include: Clinical record review revealed that Resident CR1 had [DIAGNOSES REDACTED]. The resident had a physician order [REDACTED]. Review of wound tracking documentation revealed that the open area on the coccyx was assessed and measured on December 17, 2013. The next measurement and assessment of the open area was not completed until January 2, 2014, a delay of two weeks. In an interview on September 26, 2014, at 12:50 p.m., the Nursing Home Administrator confirmed that there was a lack of documentation to indicate that staff measured and assessed the wound timely. 28 Pa. Code 211.5(f) Clinical records. ----+----+-+-+-+-+

Based on clinical record review and resident interview, it was determined that the facility failed to ensure that the resident's physician or responsible party was notified in regard to a change in the resident's medical condition for three of five sampled residents. (Residents R2, R3, R4) Findings include: Clinical record review revealed that Resident R2 had [DIAGNOSES REDACTED]. On April 15, 2014, a physican directed staff to cleanse the rods (fixation device) on the resident's left leg with normal saline, apply a medicated dressing ([MEDICATION NAME]), apply drain sponges, wrap with kling dressing and cover the area with an Ace wrap. This treatment was to be performed daily. Review of the Treatment Administration Record (TAR) for July 2014 revealed that treatment was not adminstered on July 2, 4, 6, 8, 12, 14, 16, 2014. In an interview on July 29, 2014, at 11:45 a.m., Resident R2 stated that staff tell him they have "no time" to treat his leg. There was no documentation to indicate that the physician was aware that the treatments were not provided as ordered. Clinical record review revealed that Resident R3 had [DIAGNOSES REDACTED]. An ongoing order directed staff to notify the physician if the resident's blood sugar falls below 60 milligrams per deciliter (mg/dl.)Clinical record review revealed that On July 1, 2014, at 9:00 a.m., the resident's blood sugar was 37 mg/dl. There was no documentation to indicate that the physician or responsible party was made aware of the low blood sugar. On July 14, 2014, Resident R3 had a blood sugar of 36 mg/dl at 12:40 p.m. The blood sugar remained low despite the administration of Glucogon both orally and subcutaneously. There was no documentation to indicate that the physician was made aware of the low blood sugar. Clinical record review revealed that Resident R4 had [DIAGNOSES REDACTED]. On July 18, 2014, at 6:30 p.m., the resident returned to the facility following a hospitalization for chest pain. Review of the Medication Administration Record [REDACTED]. There was no documentation to indicate that the physician was aware of the medication omissions. The resident was transferred to the emergency roiagnom on [DATE], at 4:00 a.m., due to chest pain. The physician was not notified of the transfer. 28 Pa. Code 211.12(d)(1)(5) Nursing services.