Every finding on record at Embassy of Woodland Park

Based on review of clinical records, as well as resident interviews and staff interviews, it was determined that the facility failed to ensure that residents were provided appropriately fitting incontinence products for three of 11 residents reviewed (Residents 1, 4, 11).Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated July 9, 2026, indicated that the resident was cognitively intact, dependent on two staff for daily care needs including toileting, was frequently incontinent of urine, and weighed 414 pounds. The resident's care plan, dated July 28, 2026, revealed that the resident had an indwelling urinary catheter (tube inserted directly into the bladder for urine drainage). Interview with Resident 1 on July 28, 2026, revealed that the resident had an indwelling urinary catheter. She stated that she has skin shearing on her buttock because the briefs she was made to wear were too small and too tight. She said that she was told the solution was to insert an indwelling urinary catheter. She stated that she has not had the proper sized briefs to wear since the nursing facility changed owners. She stated that she has had to wear a size 2 XL brief, despite her requiring at least a 4 XL brief. A quarterly MDS assessment for Resident 4, dated May 5, 2026, revealed that the resident was cognitively impaired, incontinent of urine and bowel, and weighed 247 pounds. Observations of Resident 4 on July 28, 2026, at 10:15 a.m. revealed that the resident was sitting in her wheelchair and had a large rotund abdomen. A quarterly MDS assessment for Resident 11, dated July 8, 2026, revealed that the resident was cognitively intact, required staff assistance for her activities of daily living, weighed 250 pounds, and that she had an indwelling urinary catheter. Observations of Resident 11 on July 28, 2026, at 10:22 a.m. revealed that she was sitting up in bed and had a large rotund abdomen. Interview with Nurse Aide 1 on July 28, 2026, at 10:25 a.m. confirmed that Residents 1, 4, and 11 all required briefs larger than size 2 XL, however, they were not available for them. She stated that central supply only provided up to size 2 XL briefs for the residents and they were tight. Interview with Central Supply Director and the Nursing Home Administrator on July 28, 2026, at 11:06 a.m. confirmed that the largest size brief their corporate office will permit to be purchased is a 2 XL. 28 Pa. Code 211.10(a)(c)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Based on review of facility policies, clinical records, observations, shower schedules, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 11 residents reviewed (Residents 11).Findings include: An annual Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 11, dated May 20, 2026, revealed that the resident was cognitively impaired, was usually able to understand others, was dependent on staff for showers/bathing, was incontinent of bowel and bladder, and had diagnoses that included cerebrovascular disease. The current care plan for Resident 11 revealed that it was very important that she choose between a tub bath, shower, bed bath, or sponge bath. Resident 11 preferred to have a bath/shower on the evening shift. Observations of Resident 11 on June 17, 2026, at 3:15 p.m. revealed that she was fully dressed and sitting in the hallway in her wheelchair. Review of the activities of daily living (ADL) documentation for Resident 11 for May and June 2026, revealed that she preferred a shower once a week on Fridays on the evening shift, However, bed baths were documented as given on May 1, May 8, May 29, and June 12 in the ADLS documentation. There was no documented evidence that the resident refused her showers on the dates listed. Interview with the Director of Nursing on June 17, 2026, at 5:21 p.m. confirmed that there was no documented evidence that Resident 11 received and/or refused her showers on the above-mentioned dates as preferred 28 Pa. Code 211.12(d)(5) Nursing services.

Based on a review of facility documents, clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to maintain resident dignity for two of seven residents reviewed (Resident 3 and Resident 4) with incontinent briefs. Findings include: The facility's current NGB & Bariatric briefs height and weight sizing chart indicated that residents would be ordered briefs based on their height and weight. Size 1/Medium: 100-150 pounds; Size 2/Large: 130-230 pounds; Size 3/XL: 210-345 pounds; Size A/Bariatric: 320-385 pounds; Size B/Bariatric: 360-440 pounds; and Size C could be used for waist sizes 90-110 inches. Observations during an interview with Resident 3 on April 8, 2026, at 11:52 a.m. revealed that she was wearing two incontinence briefs (size 2) that had been taped together by staff to fit around her. Resident 3 revealed that she was embarrassed that her briefs did not fit and stated that she had a new electric wheelchair she would like to use but was worried that the briefs would leak if she had an incontinence episode. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 17, 2026, revealed that the resident was understood, could understood others, was cognitively intact, required assistance from staff for daily care needs, was frequently incontinent of urine, and utilized electric wheelchair for mobility, and weighed 400 pounds. A care plan for Resident 3, dated October 20, 2025, revealed that it was very important that she go outside when the weather was good, and that her power wheelchair was to be used when out of bed. The NGB and Bariatric briefs height and weight sizing chart indicated that Resident 3 was to have size B/Bariatric (360-440 pounds) briefs. However, it was noted that chux pads (an absorbent disposable incontinence pad that is placed under a resident while in bed) were delivered to Resident 3 and not size B/Bariatric briefs. Observations during an interview with Resident 4 on April 8, 2026, at 1:12 p.m. revealed that the resident was in bed and was not wearing a brief that fit. Staff had cut the fastening off the side of a size 2/Large brief, so it would not scratch her. Only size 2/Large briefs were observed in Resident 4's room. A quarterly MDS assessment for Resident 4, dated March 11, 2026, revealed that the resident was always understood, always understood others, was cognitively intact, required assistance from staff for daily care needs, was always incontinent of urine and weighed 218 pounds. The NGB and Bariatric briefs height and weight sizing chart indicated that Resident 4 was to have size 3/XL briefs. Interview with Licensed Practical Nurse 1 on April 8, 2026, at 5:45 p.m. confirmed that Resident 4 was currently wearing a size 2/L, and that there were no size 3/XL available at this time. Interview with the Nursing Home Administrator and Director of Nursing on April 8, 2026, at 6:10 p.m. confirmed that the facility should supply incontinence briefs with the appropriate fit for the residents that require incontinence briefs, and also confirmed that bariatric residents (residents over 300 pounds) should be ordered briefs and not just incontinence pads. 28 Pa. Code 201.29(j) Resident Rights.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to inform the resident and/or resident representative in advance of the risks and benefits of psychotropic medication (medications that affect the persons mental state, emotions and behavior) use and the treatment alternatives prior to initiating the administration of the medication for five of 35 residents reviewed (Residents 8, 10, 11, 19 and 68). Findings Include: The facility's policy regarding the use of psychotropic medications, dated March 13, 2025, indicated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medications, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The facility would document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated October 8, 2025, revealed that the resident was cognitively impaired, received antipsychotic medications (a psychotropic medication), and had diagnoses that included dementia, post traumatic stress syndrome, and anxiety.Physician's orders for Resident 8, dated February 17, 2023, included an order for the resident to receive 25 milligrams (mg) of Cymbalta (an antidepressant medication) twice a day. Physician's orders for Resident 8, dated July 19, 2025, included an order for the resident to receive 25 mg of Cymbalta three times a day. There was no documented evidence in Resident 8's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to increasing the dose of Cymbalta.Interview with the Director of Nursing on December 4, 2025, at 1:31 p.m. confirmed that there was no documented evidence in Resident 8's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to increasing the dose of Cymbalta.A quarterly MDS assessment for Resident 10, dated October 14, 2025, revealed that the resident was cognitively impaired, received antipsychotic and antianxiety (psychotropic medication), and had diagnoses that included dementia.Physician's orders for Resident 10, dated June 2, 2025, included an order for the resident to receive 0.25 mg of lorazepam (an antianxiety medication) once daily for generalized anxiety. Physician's orders for Resident 10, dated November 4, 2025, included an order for the resident to receive 0.5 mg of lorazepam twice daily for generalized anxiety.There was no documented evidence in Resident 10's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating an increased dose of lorazepam.Interview with the Director of Nursing on December 4, 2025, at 11:01 a.m. confirmed that there was no documented evidence in the Resident 10's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to increasing lorazepam.An admission MDS assessment for Resident 11, dated October 14, 2025, revealed that the resident was cognitively impaired, received antianxiety medications, and had diagnoses that included dementia. Physician's orders for Resident 11 , dated August 30, 2025, included an order for the resident to receive 0.5 mg of Rexulti (an antipsychotic medication) daily for dementia with behavioral disturbance. Interview with the Director of Nursing on December 4, 2025, at 11:01 a.m. confirmed that there was no documented evidence in the Resident 11's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Rexulti.A quarterly MDS assessment for Resident 19, dated October 13, 2025, revealed that the resident was cognitively impaired, received antidepressant medications, and had a diagnosis of depression.A psychiatric evaluation and consultation note for Resident 19, dated June 7, 2025, revealed recommendations to discontinue the resident's Seroquel (an antipsychotic medication used to treat mental health disorders) and increase the resident's Zoloft (an antidepressant medication) from 50mg to 75 mg daily.Physician's orders for Resident 19, dated June 7, 2025, included orders for the resident to receive 75 mg of Zoloft daily.There was no documented evidence in Resident 19's clinical record to indicate that the residents representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Zoloft.Interview with the Director of Nursing on December 4, 2025, at 11:01 a.m. confirmed that there was no documented evidence in the Resident 19's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating the increased dose of Zoloft.An admission MDS assessment for Resident 68, dated October 8, 2025, revealed that the resident was cognitively impaired, received antipsychotic medications, and had diagnoses that included Alzheimer's dementia.Physician's orders for Resident 68, dated November 23, 2025, included an order for the resident to receive 0.5 mg of Rexulti daily for 7 days to begin November 24, 2025, through December 1, 2025; then 1 mg of Rexulti daily for 7 days to begin December 1, 2025, through December 8, 2025; then Rexulti 2 mg daily to begin December 8, 2025.There was no documented evidence in Resident 68's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Rexulti.Interview with the Director of Nursing on December 4, 2025, at 11:01 a.m. confirmed that there was no documented evidence in the Resident 68's clinical record that the resident's representative was informed in advance of the risks and benefits and treatment alternatives prior to initiating Rexulti.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(2) Management.28 Pa. Code 201.29(a): Resident rights.

Based on facility policies, observations, and staff interviews, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.Findings include:Observations of the walk in cooler on December 1, 2025, at 9:50 a.m. and December 3, 2025 at 1:43 p.m. respectively, revealed a shelving unit with an opened box of eggs and a box containing cartons of liquid eggs being stored on the bottom shelf, which was approximately 1.0 to 1.5 inches off the ground. On the floor beneath the shelving unit was debris including individual butter containers and brown onion skins.Interview with the Dietary Director on December 3, 2025, at 1:43 p.m. indicated that food should be stored at least six inches off the ground and confirmed that the floor underneath the shelf should be free of debris and food items that had fallen. The shelves were recently put in by maintenance.Observations of the facility's dishwasher on December 3, 2025, at 1:24 p.m. revealed that it was a high temperature dishwasher that was converted to a low temp dishwasher with chemical sanitization. There were two dietary staff in the dish room washing dishes at that time and multiple attempts were made to test the sanitization, but the testing strips remained white with no indication of sanitizer in the reading. Interview with the Dietary Manager on December 3, 2025, and again on December 4, 2025, at 12:58 at the time of observation, confirmed that the chemicals were just changed out recently and the machine was serviced on December 3, 2025. There were two companies coming in on December 5, 2025 to check the machine. The sanitizer does not work consistently and the facility has been washing the dishes by hand utilizing the three bin sink.28 Pa. Code 211.6(f) Dietary Services.28 Pa. Code 207.4 Ice Containers and Storage.

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' dining and activity areas (100 hall), and for two residents who had holes in fitted sheets (Resident 18, 64). Findings include:Observations of the 100 hall dining room on December 1, 2025, at 12:11 p.m. revealed that there were three people eating in the room. There was a small vase of flowers sitting on the windowsill and approximately 30 dead insects that were light brown and dried out also on the windowsill. Observations of the 100 hall dining/activity room on December 3, 2023, at 3:32 p.m. revealed dead insects on the windowsill.Interview with Nurse Aide 1 on December 3, 2025, at 3:32 p.m. confirmed that there were dead insects on the windowsills and that they should have been cleaned up.Interview with the Director of Housekeeping on December 4, 2025, at 10:42 a.m. confirmed that there should not have been any dead insects in the areas mentioned.Observations of Resident 18's bed on December 4, 2025, at 10:45 a.m. revealed that there was a hole approximately 5 millimeters (mm) in size by the head of her fitted sheet. The sheets were very thin and see-through.Observations of Resident 64's bed on December 4, 2025, at 11:02 a.m. revealed that there was a hole approximately 3 mm in size in the bottom of his fitted sheet, and his sheets were very thin and see-through.Interview with the Director of Laundry on December 5, 2025, at 10:49 a.m. revealed that they were able to use sheets with holes as long as the hole was no bigger than the eraser tip of a pencil.Interview with the Director of Nursing on December 5, 2025, at 10:56 a.m. confirmed that the sheets with holes should have been thrown out and not used.28 Pa. Code 201.29(j) Resident rights.

Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for one of 35 residents reviewed (Resident 4). Findings include:The facility's policy for the use of psychotropic medications, dated March 13, 2025, indicated that psychotropic medications used on an as needed (PRN) basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and was subject to the limitations as noted: PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration.An admission Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for Resident 4, dated September 13, 2025, indicated that the resident was cognitively impaired, received antidepressant and antianxiety medications (psychotropic medications), and had diagnoses that included dementia, depression, and anxiety.Physician's orders for Resident 4, dated October 2, 2025, included an order for the resident to receive 0.5 milligrams (mg) of Xanax (a psychotropic medication used to treat anxiety) every twelve hours as needed for anxiety.Review of the Medication Administration Record (MAR) for Resident 4, dated October 2025, revealed that 0.5 mg of Xanax was administered to the resident on October 19 at 5:03 p.m.; October 21 at 3:51 p.m.; October 23 at 11:29 a.m.; and October 26 at 1:23 p.m.There was no was duration included in the physician's order and no documented evidence from a physician or prescriber to indicate the rationale to extend the as needed medication beyond 14 days.Interview with the Director of Nursing on December 4, 2025, at 11:01 a.m. confirmed that there was no duration included in the physician's order on October 2, 2025, and no documented evidence from a physician or prescriber to indicate the rationale to extend the as needed Xanax for Resident 4 beyond 14 days.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and the resident's representative, in writing regarding the reason for transfer to the hospital, to ensure that a bed-hold notice was provided to the resident's responsible party and that the ombudsman was notified of the transfer to the hospital, for three of 35 residents reviewed (Residents 9, 40, 46). Findings include:A quarterly minimum data set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated September 10, 2025, indicated that the resident was cognitively intact, required assistance from staff for all daily care needs, and had diagnoses that included heart failure and end stage kidney disease.A nursing note for Resident 9, dated February 2, 2025, at 11:48 a.m. revealed that the resident had increased weakness and was slow to respond at dialysis, and the resident was being sent to the emergency room. A nursing note dated July 4, 2025, at 10:06 a.m. revealed that the resident was bleeding profusely at the dialysis site and was being sent to the emergency room. A nursing note dated October 8, 2025, at 10:28 a.m. revealed that the resident's fistula site was unable to be accessed during dialysis and the resident was being sent to the emergency room. A nursing note dated November 5, 2025, at 5:43 p.m. revealed that the resident's surgical site was bleeding profusely and she was being sent to the emergency room. A nursing note dated November 24, 2025, at 3:30 a.m. revealed that the resident was having redness around her port site and was not feeling herself and was being sent to the emergency room. There was no documented evidence that written notification of transfer to the hospital was provided to Resident 9 or the resident's representative, no documented evidence that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of her transfer to the hospital on the above dates and times as required.Interview with the Director of Nursing on December 4, 2025, at 11:18 a.m. confirmed there was no written notification of hospital transfer provided to the resident or their representative, that a bed-hold notice was not provided to their responsible party, and that the ombudsman was not notified of the transfer to the hospital on the above dates and times as required.An annual MDS assessment for Resident 40, dated September 15, 2025, indicated that the resident was cognitively impaired, required substantial assistance from staff for all daily care needs, and had diagnoses that included high blood pressure, high cholesterol, and dementia.A nursing note for Resident 40, dated June 9, 2025, at 10:53 a.m., revealed that the resident was having a large amount of bleeding from his urinary catheter, and hernias and tenderness in his abdomen, and was sent to the emergency room.There was no documented evidence that written notification of transfer to the hospital was provided to the resident's representative, no documented evidence that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of her transfer to the hospital on the above date and time as required.A quarterly MDS assessment for Resident 46, dated October 20, 2025, revealed that the resident was cognitively impaired and required maximum assistance from staff for daily care needs.A nursing note for Resident 46, dated July 18, 2025, at 6:25 p.m., revealed that the resident was found on the floor and was very disoriented, and was sent to the emergency room for evaluation.There was no documented evidence that written notification of transfer to the hospital was provided to the resident's representative, no documented evidence that a bed-hold notice was provided to the resident's responsible party, and no documented evidence that the ombudsman was notified of her transfer to the hospital on the above date and time as required.Interview with the Director of Nursing on December 4, at 2:54 p.m. confirmed that for Residents 40 and 46 there was no written notification of hospital transfers provided to the resident's representative or ombudsman, and that a bed hold notice was not provided.28 Pa. Code 201.29(j) Resident Rights.

Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive significant change Minimum Data Set assessments were completed in the required time frame for two of 35 residents reviewed (Residents 14 and 102). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that the Assessment Reference Date (ARD) was to be no later than the 14th calendar day after determination that a significant change in the resident's status occurred (determination date + 14 calendar days) and the significant change comprehensive MDS assessment was to be completed no later than the 14th calendar day after determination that significant a change in the resident's status occurred (determination date + 14 calendar days).Review of the clinical record for Resident 14 revealed that a significant change in condition was identified on September 25, 2025 and the resident was admitted to hospice services with a diagnosis of Alzheimer's.A significant change MDS assessment for Resident 14, dated October 1, 2025, revealed that the MDS was documented in section Z0500B as being completed on October 13, 2025, which was five days late.Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on December 4, 2025, at 2:59 p.m. confirmed that the significant change comprehensive MDS assessment for Resident 14 should have been completed by October 8, 2025, and it was not.Review of the clinical record for Resident 102 revealed that a significant change in condition was identified on November 18, 2025 and the resident was admitted to hospice services with a diagnosis of vascular dementia.A significant change MDS for Resident 102, dated December 1, 2025, revealed that the MDS was not signed in section Z0500B as completed.Interview with the Registered Nurse Assessment Coordinator on December 4, 2025, at 2:39 p.m. confirmed that the significant change MDS assessment for Resident 102 should have been completed by December 1, 2025, and was still in progress.28 Pa. Code 211.5(f) Clinical Records.

Based on review of clinical records and staff interviews, it was determined that the facility failed to follow physician's orders to notify the physician of changes in weight for a resident with edema (fluid retention in body tissues) for one of 35 resident's reviewed (Resident 34), and failed to ensure that medications were provided as ordered by the physician for one of 35 residents reviewed (Resident 62).Findings include:An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated September 26, 2025, revealed that the resident was cognitively impaired, required assistance for care needs, received a diuretic (water pill) medication, and had a diagnosis that included heart failure (the heart can't pump blood as well as it should causing weight gain due to fluid to build up in the lungs and lower legs).Physician's orders for Resident 34, dated November 12, 2025, included an order for the staff to weigh the resident daily for weight gain/increase in edema and to notify the physician for a weight gain of greater than three pounds.A review of Resident 34's clinical record and Treatment Administration Record (TAR) for November 2025, revealed that the resident's weight on November 19 was 195.3 pounds and the resident's weight on November 20 was 203.2 pounds, indicating a 7.9 pound weight gain. The resident's weight on November 23 was 193.7 pounds and the resident's weight on November 24 was 203.2 pounds, indicating a 9.5 pound weight gain. The resident's weight on November 27 was 203.6 pounds and the resident's weight on November 28 was 208.8 pounds, indicating a 5.2 pound weight gain. There was no documented evidence that the physician was notified of the resident's weight gain of greater than three pounds on November 20, November 24 and November 28.An interview with the Director of Nursing on December 3, 2025, at 11:18 a.m. confirmed that there was no documented evidence that the physician was notified of Resident 34's weight gain of greater than three pounds on November 20, November 24 and November 28.An annual MDS assessment for Resident 62, dated September 18, 2025, revealed that the resident was cognitively intact, required assistance for care needs, and had a diagnosis that included high blood pressure.Physician's orders for Resident 62, dated October 31, 2025, included an order for the resident to receive 12.5 milligrams (mg) of metoprolol daily and to hold the medication if the pulse was less than 55.A review of Resident 62's Medication Administration Record (MAR) for November 2025, revealed that the resident's pulse was 53 on November 26, 2025, and 42 on November 28, 2025, and metoprolol was administered.An interview with the Director of Nursing on December 4, 2025, at 1:18 p.m. confirmed that the metoprolol was administered on the above dates and times and should not have been.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that an updated order was obtained for the correct foley size available for urinary catheterization (a flexible tube inserted into the bladder to drain urine) was completed as ordered for one of 31 residents reviewed (Resident 40). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40 dated September 15, 2025, revealed that the resident was cognitively impaired, required assistance for care needs, and had a diagnosis of neurogenic bladder (a bladder dysfunction causing urinary incontinence or retention).Physician's orders for Resident 40, dated April 30, 2024, included an order for the resident to use an 18 french (size) foley catheter with a 30cc balloon, and may use a 5-10cc balloon if a 30cc balloon was not available.A nursing note for Resident 40, dated October 30, 2025, at 2:03 a.m. revealed that the resident's catheter was not able to be flushed and a 16 french 30cc foley catheter was inserted.Interview with Licensed Practical Nurse 2 on December 3, 2025, at 10:48 a.m. revealed that if they run out of the foley catheter, a provider was to be notified, and a new order obtained.Interview with the Director of Nursing on December 4, 2025, at 11:49 a.m. confirmed that the provider should have been notified that the ordered catheter was not available and a new order should have been obtained.28 Pa. Code 211.12(d)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to flush an intravenous catheter (a thin tube inserted into a vein to administer medications and/or fluids) per facility policy for one of 35 residents reviewed (Resident 34). Findings include:The facility's policy regarding intravenous catheter flushing, dated March 13, 2025, indicated that catheters were to be flushed at regular intervals to maintain patency, before and after administration of medications. Staff were to use only preservative free 0.9 % sodium chloride for saline flushes (a mixture of water and salt, with a salt concentration of 0.9%).An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 34, dated September 26, 2025, revealed that the resident was cognitively impaired, required assistance for care needs, received an antibiotic and intravenous medications, and had a diagnosis that included Osteomyelitis (an infection of the bone).Physician's orders for Resident 34, dated November 4, 2025, included an order for the resident to receive two grams (gm) of Ceftriaxone (an antibiotic) intravenously daily for five days.A review of Resident 34's Medication Administration Record (MAR), dated November 2025, revealed that staff administered the two gm of Ceftriaxone intravenously daily on November 4 and 5, 2025; however, there was no documented evidence that Resident 34's intravenous line was flushed with saline solution before and after the administration of the Ceftriaxone. Interview with the Director of Nursing on December 3, 2025, at 11:18 a.m. confirmed that there was no documented evidence that Resident 34's intravenous line was flushed with a saline solution before and after the administration of the Ceftriaxone.28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 35 residents reviewed (Resident 8).Findings include: A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated November 3, 2025, indicated that the resident was cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included depression, anxiety, and PTSD. A review of Resident 46's care plan, dated August 13, 2024, indicated that the resident had PTSD, anxiety, and Traumatic Brain Injury. There was no documented evidence the facility identified Resident 8's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring. Interview with the Nursing Home Administrator on December 4, 2025, at 2:15 p.m. revealed that she believed Resident 8 did not trigger PTSD and if the doctor thought it was a real diagnosis the resident would have been reassessed for it quarterly. Interview with the Medical Director on December 4, 2025, at 2:12 p.m. revealed that Resident 8 was admitted with the diagnosis of PTSD and that she was told by the family that the resident was diagnosed with it years ago. The medical director further stated that she believes the daughter would know the resident better than anyone. 28 Pa Code 201.24(e)(4) admission Policy. 28 Pa Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plan of corrections for an annual survey ending October 3, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending December 4, 2025, identified repeated deficiencies related to a homelike environment and safe and sanitary food storage. The facility's plan of correction for a deficiency regarding a homelike environment cited during the survey ending October 3, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F584, revealed that the facility's QAPI committee failed to successfully implement their plan regarding a homelike environment. The facility's plan of correction for a deficiency regarding safe and sanitary food storage cited during the survey ending October 3, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to successfully implement their plan regarding safe and sanitary food storage. Refer to F584, F812. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(e)(1) Management.

Based on review of facility policies and observations, as well as staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.The facility's current policy regarding food temperatures, dated March 13, 2025, indicated that the serving temperature of hot food at point of service should have a temperature of greater than or equal to 120 degrees Fahrenheit (F).The menu for Monday, August 19, 2025, revealed that the lunch meal included baked fish, broccoli rice casserole, seasoned broccoli, and frosted cake. Observations in the main kitchen service area on August 19, 2025, revealed that the food cart to the 100 unit left the main kitchen at 11:54 a.m. and arrived on the 100 unit at 11:55 a.m. Trays were passed to the residents in their rooms and the last resident was served at 12:08 p.m. At 12:08 p.m. the temperature of the seasoned broccoli was 111.0 degrees F. The broccoli was lukewarm and did not taste appetizing. Interview with the Dietary Manager on August 19, 2025 at the time of the observation confirmed that the broccoli should have been hotter. 28 Pa. Code 211.6(b) Dietary Services.

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's representative was notified about a change in condition for one of three residents reviewed (Resident 3).Findings include: An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated May 28, 2025, revealed that the resident was cognitively intact, required maximum assistance from staff for daily care needs, and had a diagnosis of a stroke.A nursing note for Resident 3, dated May 26, 2025, at 5:47 a.m., revealed that the resident was found on the floor in front of her wheelchair and was attempting to get herself off of the floor. There was no documented evidence in Resident 3's clinical record to indicate that her emergency contact was notified of the fall until May 29, 2025, at 8:54 a.m. (three days later).Interview with the Director of Nursing on July 7, 2025, at 10:26 a.m. confirmed that Resident 3's emergency contact was not notified until three days after the fall but should have been notified immediately28 Pa. Code 211.12(d)(3)(5) Nursing Services.

Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of five residents reviewed (Resident 4). Findings include: The facility's policy regarding medication administration, dated March 13, 2025, indicated that medications are to be administered by licensed nurses in accordance with professional standards. Staff are to compare the medication source (bubble pack, vial, etc) with the Medication Administration Record (MAR) to verify the resident name, medication name, form, dose, route, and time. The staff are to observe resident consumption of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 2, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had constipation and dementia. A care plan for Resident 4, dated April 29, 2024, revealed that the resident was at risk for constipation and complained of gas pains at times. Staff were to administer medications as ordered by the physician. Physician's orders for Resident 4, dated September 10, 2024, included an order for the resident to receive 8.6-50 milligrams of senna-docusate sodium (stool softening medication) with instructions to give three tablets by mouth once time a day for constipation at 8:00 p.m. Observations of Resident 4 on April 4, 2025, at 4:24 p.m., revealed that she was lying down in bed, and there was a medication cup with three red pills and a cup of water on the over-bed table. Resident 4 sat up and took the pills. Interview with Licensed Practical Nurse 1 on March 1, 2025, at 4:47 p.m. confirmed that she left the medication at bed side, and it was to be administered in the evening. She identified the medication as senna-docusate. Interview with the Director of Nursing on April 1, 2025, at 5:17 p.m. confirmed that licensed staff responsible for medication administration should administer the medication at the physician-ordered time. 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to store medication appropriately for one of five residents reviewed (Resident 4). Findings include: The facility's policy regarding medication administration, dated March 13, 2025, indicated that medications are to be administered by licensed nurses in accordance with professional standards. Staff are to compare the medication source (bubble pack, vial, etc) with the Medication Administration Record (MAR) to verify the resident name, medication name, form, dose, route, and time. The staff are to observe resident consumption of the medication. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated February 2, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had constipation and dementia. A care plan for Resident 4, dated April 29, 2024, revealed that the resident was at risk for constipation and complained of gas pains at times. Staff were to administer medications as ordered by the physician. Physician's orders for Resident 4, dated September 10, 2024, included an order for the resident to receive 8.6-50 milligrams of senna-docusate sodium (stool softening medication) with instructions to give three tablets by mouth once time a day for constipation at 8:00 p.m. Observations of Resident 4 on April 4, 2025, at 4:24 p.m. revealed that she in room [ROOM NUMBER] bed A on the locked memory unit of the facility. She was lying down in bed, and there was a medication cup with three red, round tablets and a cup of water on the over-bed table. Resident 4 sat up and took the pills. Interview with Licensed Practical Nurse 1 on March 1, 2025, at 4:47 p.m. confirmed that she left the medication at bed side and she should not have. Interview with the Director of Nursing on April 1, 2025, at 5:07 p.m. confirmed that licensed staff responsible for medication administration should remain with the resident and observe the resident ingest the medication, and not leave it at bedside. 28 Pa. Code 211.9(a)(1) Pharmacy Services. 28 Pa. Code 211.12(d)(1) Nursing Services.

Based on a review of facility policy and the facility's written menus, as well as observations and staff and resident interviews, it was determined that the facility failed to follow their planned menu. Findings include: A facility policy, dated March 15, 2024, indicated that menus shall be written in advance and followed. Any menu substitutions shall be made in an emergency situation only and recorded on the substitution log. An interview with a group of residents on October 1, 2024, indicated that the kitchen does not always serve what is on the menu. Observations of the kitchen on September 30, 2024, at 9:58 a.m. revealed that staff were preparing meatloaf, mashed potatoes, mixed vegetables (carrots, green beans, and wax beans), and vanilla cake for lunch. The facility's written and printed menu for the lunch meal on September 30, 2024, revealed that the residents were to receive meatloaf, mashed potatoes, Brussels sprouts, berry-topped yellow cake, coffee/tea, dinner roll, and margarine. Observations of the lunch meal in the dining room on September 30, 2024, at 12:14 p.m. revealed that the facility prepared and served Prince [NAME] veggie blend (green beans, wax beans, and carrots). Interview with [NAME] 6 on September 30, 2024, at 12:14 p.m. confirmed that she was unsure what was to be on the menu, but she did not have Brussels sprouts to serve for lunch. The only vegetable she had was a carrot, green bean, and wax bean mix. Interview with the Dietary Manager on September 30, 2024, at 12:17 p.m. confirmed that she forgot to order Brussels sprouts and substituted with the Prince [NAME] mix. She did not inform residents or the resident council president of the menu change. The facility's recipe for chicken breast citrus glazed (ground), undated, indicated that two fluid ounces of citrus wing sauce was to be served with one scoop of ground chicken. Observations of tray line on October 1, 2024, at 12:08 p.m., revealed that the regular texture trays had a chicken breast dipped in a liquid glaze, but the scoop of ground chicken breast had poultry gravy added on top of the serving and not the citrus glaze. A test tray on October 1, 2024, at 12:25 p.m. revealed that the chicken breast with citrus glaze of ground texture did not taste the same as the regular texture chicken breast. The ground chicken did not have a citrus glaze and had a poultry gravy flavor. Interview with the Dietary Director on October 1, 2024, at 12:32 p.m. confirmed that the ground chicken did not have the citrus glaze and should have.

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to prepare and store food in accordance with professional standards for food service safety. Findings include: A facility policy for food storage, dated March 15, 2024, revealed that all items being stored in the freezer must be labeled, dated, and sealed in the same manner and may be stored for the period of time per Hazardous Analysis Critical Control Point (HACCP - a systematic approach to the identification, evaluation, and control of food safety hazards) guidelines. Dry storage items must be six inches off the floor. Observations of the main kitchen during the initial tour on September 30, 2024, at 9:55 a.m. revealed that there were two cardboard boxes of coffee on the floor stacked one on top of the other. Observations in the three-door freezer on September 30, 2024, at 9:58 a.m. revealed a box with approximately two thirds of a chocolate cake that was not dated, labeled, or sealed. Interview with Dietary Director on September 30, 2024, at 10:08 a.m. confirmed that the coffee should not be stored directly on the floor and that the chocolate cake in the freezer should be dated, labeled, and sealed. 28 Pa. Code 211.6(f) Dietary Services.

Based on a review of manufacturer's directions, clinical records, incident/accident reports, staff training records, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to ensure that safe techniques were used during a transfer onto a mechanical wheelchair lift for one of three residents reviewed (Resident 2), resulting in a head injury. Findings include: Manufacturer's directions for use of the [NAME] Corporation FMVSS Public Use Lift (the type of lift platform in the facility's wheelchair van), undated, indicated that the lift platform must be positioned at floor level when loading and unloading in and out of the vehicle. The lift operator would load and unload the wheelchair passenger on the lift and use the up and down switch to control the movement of the platform. A visual and audible warning would activate if the threshold area was occupied when the platform was greater than one inch below floor level of the van. The bus and van competency checklist for Nurse Aide/Transporter 1, dated November 30, 2023, revealed that staff received training prior to operating the electronic lift of the vehicle and demonstrated proper procedure for using the lift to load standard and electric wheelchairs. Nurse Aide/Transporter 1 met the standard to raise and lower the lift platform safely and in the correct position. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 21, 2024, revealed that the resident was cognitively intact, required extensive assistance from staff for her daily care including transfers, and used a wheelchair. A nursing note and incident report for Resident 2, dated June 26, 2024, at 3:26 p.m. revealed that the resident was lying on her left side on the pavement with her head on the lift platform that is used to load and unload residents from the van. Nursing notes for Resident 2, dated June 26, 2024, at 4:16 p.m. revealed that the resident had a skin tear on her right forearm and right foot, an abrasion on her right knee, scratches on her knuckles, and a 2.5 centimeter (cm) x 2.5 cm lump on the back of her head. A nursing note for Resident 2, dated June 26, 2024, at 5:06 p.m. revealed that the resident was sent to the hospital for a CT scan (diagnostic imaging test) after a fall with head injury. A statement from Nurse Aide/Transporter 1, undated, revealed that she unhooked the safety hooks, seatbelt, and wheelchair locks for Resident 2 and backed her up to the back of the van. Nurse Aide/Transporter 1 had to brace her feet to the safety hook bracket and pushed with her legs to pull Resident 2 over the lip of the lift because of her weight. Nurse Aide/Transporter 1 stepped back on the lift and realized that the lift was not in proper position. Nurse Aide/Transporter 1 attempted to push Resident 2 forward, but with the momentum the alarm plate flipped back towards her and both Nurse Aide/Transporter 1 and Resident 2 fell . Information submitted by the facility on June 27, 2024, revealed that Nurse Aide/Transporter 1 pushed Resident 2 out of the van to get on the lift and as she stepped over the alarming plate, the alarm did not sound to inform the Nurse Aide/Transporter 1 that the lift was down and not up. Nurse Aide/Transporter 1 and Resident 2 fell backwards before the lift was returned to the upper position from the previous transfer. Resident 2's head was in contact with the edge of the lift platform, and the mid upper occipital area was swelling and there was a small laceration. Resident 2 was sent to the local emergency room and was then transferred to another hospital after a subdural hematoma (bleeding in the brain) was noted. Hospital discharge records for Resident 2, dated June 30, 2024, revealed that she was seen for a fall and head injury. Resident 2 was seen and evaluated by the neurosurgery team for bleeding in the brain. Resident 2's coumadin (a blood thinner medication) needed to be reversed to help prevent the bleed from increasing. Resident 2 was started on Keppra (antiseizure medication) for seven days for prevention of seizures. Interview with Nurse Aide/Transporter 1 on June 26, 2024, at 2:45 p.m. confirmed that she was unaware that the other Nurse Aide/Transporter did not put the lift platform back to the up position. She did not look behind her, because she was focused pushing Resident 2 out of the van without hitting her arms on the sides of the lift. When she was going to push Resident 2 onto the lift platform, she stepped over the alarm plate and the alarm did not sound that the lift was not in the up position. However, Resident 2's momentum did not allow Nurse Aide/Transporter 1 to push the resident back into the van. Both fell from the van, and Resident 2 landed on top of Nurse Aide/Transporter 1 and hit her head. Interview with the Director of Nursing on July 10, 2024, at 12:42 p.m. confirmed that Nurse Aide/Transporter 1 did not ensure that the lift was in the up position when pushing Resident 2 out of the van, resulting in a fall with a head injury. 28 Pa. Code 201.14(a) Responsibility of Licensee. 28 Pa. Code 201.18(b)(1)(e)(1) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.

Based on review of manufacturer's directions, job descriptions, clinical records, incident/accident reports, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to ensure that safe techniques were used during a mechanical wheelchair lift transfer from a vehicle for one of two residents reviewed (Resident 1), resulting in a head injury for the resident. Findings include: Manufacturer's directions for use of the[NAME]Century 2 Series hydraulic wheelchair lift (the type of lift platform in the facility's wheelchair van), dated (MONTH) 2010, indicated that the lift platform must be positioned at floor level when loading or unloading in and out of the vehicle, and it was the responsibility of the lift operator (attendant) to load and unload the wheelchair passenger on and off the lift. The job description for a driver, dated (MONTH) 1, 2019, indicated that the driver would safely assist residents in and out of the vehicle and would operate the lift equipment necessary to load and unload wheelchairs. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated (MONTH) 5, 2019, revealed that the resident was cognitively intact, required extensive assistance from staff for her daily care, including transfers, and used a wheelchair. An incident report for Resident 1, dated (MONTH) 12, 2019, at 1:40 p.m. and nursing note dated (MONTH) 12, 2019, at 2:48 p.m. revealed that the resident was being transferred out of the transport van and her wheelchair flipped off the van ramp and she hit her head. The resident complained of increased pain and was sent to the emergency room . Information submitted by the facility on (MONTH) 14, 2019, revealed that the van driver pushed Resident 1 out of the van to get on the lift and an alarm sounded to inform the driver that the lift was down and not up. The driver had the resident too close to the edge of the van and the resident and wheelchair rolled out of the back of the van. The wheelchair hit the ground and flipped backward with the resident in it, and the resident struck her back and the back of her head off a slide board that was in a bag behind her wheelchair. She complained of a headache and mid-back pain and was transferred to the hospital for evaluation. Hospital records for Resident 1, dated (MONTH) 12, 2019, revealed that she was seen for a fall and head injury after her wheelchair fell over and she hit her head and back. She was receiving 5 milligrams of Eliquis (a blood thinner) twice a day, complained of a headache and mid-back pain, vomited once, and her mental status continued to deteriorate. A CT-scan (diagnostic imaging test), dated (MONTH) 12, 2019, revealed that the resident had subdural hemorrhages (bleeding that often occurs outside the brain as a result of a severe head injury). A statement from Van Driver 1, dated (MONTH) 12, 2019, revealed that she put the lift platform in the back of the van in a down position to the ground to allow another resident be taken into the facility. She forgot to bring the lift platform back up and level with the back of the van, and she pushed Resident 1 backward out the back of the van without the lift platform being in place. The resident landed on the lift platform that was positioned on the ground and hit her head and back. Interview with Van Driver 1 on (MONTH) 18, 2019, at 1:11 p.m. confirmed that she forgot to put the lift platform back up and when she was going to push Resident 1 onto the lift platform, the alarm sounded that the lift was not in the up position; however, the resident (in her wheelchair) was too far off the back of the van and she fell from the van, hitting her head and back. Interview with the Director of Nursing on (MONTH) 18, 2019, at 12:15 p.m. confirmed that the van driver did not put the lift in the up position when pushing Resident 1 out of the van, the resident fell approximately twenty-seven inches from the van to the ground, hit her head and back, and was transferred to the hospital for evaluation. 42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices. Previously cited 3/22/19, 1/5/18. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 4/22/19, 3/22/19, 1/10/19. 28 Pa. Code 201.18(e)(1) Management. Previously cited 4/22/19, 3/22/19, 1/10/19. 28 Pa. Code 211.12(d)(3) Nursing services. Previously cited 3/22/19, 1/10/19, 2/9/18, 1/5/18. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 8/19/19, 4/22/19, 3/22/19, 1/10/19, 2/9/18, 1/5/18.

Based on review of policies, clinical records, incident reports and dietary meal tickets, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that residents were not served foods they were allergic to for one of 11 residents reviewed (Resident 2), which caused harm with an allergic reaction; failed to ensure that all written sources of information about residents' food allergies were consistently and accurately documented for five of 11 residents reviewed (Residents 2, 9, 11, 12, 13); and failed to accommodate each resident's food preferences for three of 11 residents reviewed (Residents 4, 5, 9). Findings include: The facility's policy regarding dietary meal and tray identification dated (MONTH) 7, (YEAR), indicated that dietary tickets were used to identify correct food items for residents' meals and preferences. However, the policy did not address the identification of food allergies. A comprehensive annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2 dated (MONTH) 9, (YEAR), revealed that the resident was confused, was on a mechanically altered diet, had swallowing problems, and could eat independently after set up. Physician orders [REDACTED]. The resident's care plan dated (MONTH) 21, (YEAR), revealed that the resident had food allergies to oysters, shellfish and strawberries. The facility's investigation into an incident for Resident 2 dated (MONTH) 8, (YEAR), revealed that the resident was served and consumed fish and clam chowder (contains clams, which are a type of shellfish), in which she had an allergic reaction. The resident's dietary ticket for the supper meal on (MONTH) 8, (YEAR), indicated that Resident 2 disliked oysters and had food allergies to oysters and strawberries. A nursing note dated (MONTH) 8, (YEAR), revealed that the resident had a red face, breathing difficulties, hives, and a blood oxygenation saturation of 80 percent. A written statement from Dietary Staff 2 dated (MONTH) 8, (YEAR), indicated that she served Resident 2 fish and clam chowder because the resident's family member said that the resident could have fish. A nursing note written by Licensed Practical Nurse 5 dated (MONTH) 8, (YEAR), at 6:15 p.m. revealed that she was told that Resident 2 ate seafood and had an allergy to it. She then notified the registered nurse that the resident was coughing, had trouble catching her breath, and that her face was bright red. An ambulance was called and Resident 2 was sent to the emergency room . An emergency department report for Resident 2 dated (MONTH) 8, (YEAR), revealed that the resident was given fish and clam chowder and had multiple hives on the anterior (front) chest wall. She was treated with [MEDICATION NAME] (a steroid that suppresses the immune system) and an [MEDICATION NAME] (a medication to stop allergy symptoms), which resolved her allergic reaction. Interview with Dietary Staff 2 on (MONTH) 5, (YEAR), at 2:00 p.m. confirmed that she served Resident 2 clam chowder and fish on (MONTH) 8, (YEAR), and at that time, the resident's meal ticket indicated that she had allergies to oysters and strawberries. Observations during the breakfast meal on (MONTH) 3, (YEAR), at 7:55 a.m. revealed that Resident 2's dietary meal ticket was changed to indicate food allergies to shellfish and strawberries. The facility failed to maintain an accurate list of Resident 2's food allergies resulting in a severe allergic reaction requiring treatment at a hospital. Review of care plans, dietary meal tickets, dietary progress notes, face sheets (a form that contains general information about the resident), and/or a list of food allergies kept in the kitchen for Residents 2, 9, 11, 12 and 13 revealed that not all written sources containing information about food allergies were consistently and accurately documented as follows: Resident 2's care plan dated (MONTH) 21, (YEAR), revealed that the resident had food allergies to oysters, shellfish and strawberries. However, the resident's dietary meal ticket listed allergies to shellfish and strawberries, and the resident's face sheet, dated (MONTH) 20, (YEAR), listed allergies to oysters and strawberries. Resident 9's care plan dated (MONTH) 21, (YEAR), revealed that the resident had no food allergies and the plan included no interventions related to allergies or allergic reactions. However, Resident 9's dietary meal ticket indicated that the resident had an allergy to strawberries, and the resident's face sheet, dated (MONTH) 20, (YEAR), listed no food allergies. Resident 11's care plan dated (MONTH) 21, (YEAR), revealed that the resident had no food allergies and the plan included no interventions related to allergies or allergic reactions. However, the resident's dietary meal ticket indicated that Resident 11 had an allergy to raisins, and the resident's face sheet, dated (MONTH) 20, (YEAR), listed no food allergies. A Food Allergy list that was posted on a refrigerator in the kitchen indicated that Resident 12 had a food allergy to strawberries. However, Resident 12's dietary meal ticket listed strawberries under dislikes not under allergies. A Food Allergy list that was posted on a refrigerator in the kitchen indicated that Resident 13 had a food allergy to mushrooms. However, Resident 13's dietary meal ticket listed mushrooms under dislikes not under allergies. A comprehensive annual Minimum Data Set (MDS) assessment for Resident 9 dated (MONTH) 25, (YEAR), revealed that the resident could express her needs and could eat independently after set-up. Resident 9's care plan dated (MONTH) 3, (YEAR), indicated that corn was to be avoided because the resident had difficulty chewing and swallowing corn. A speech therapy note dated (MONTH) 22, (YEAR), indicated that the resident had trouble with some food items resulting in choking. Review of Resident 9's dietary meal ticket on (MONTH) 3, (YEAR), revealed that the ticket indicated that the resident disliked lima beans and to avoid corn. Interview with Resident 9 on (MONTH) 3, (YEAR), at 12:00 p.m. revealed that she was on a regular diet and had trouble swallowing. She stated that the girls knew her allergies and food preferences and that they were listed on her dietary ticket. Observation of Resident 9's lunch meal on (MONTH) 3, (YEAR), at 12:50 p.m. revealed that Licensed Practical Nurse 1 delivered the meal tray to the resident with corn and lima beans on it (succotash). Interview with Licensed Practical Nurse 1 on (MONTH) 3, (YEAR), at 12:50 p.m. revealed that she sent a note to the dietary department to inform them that Resident 9 requested not to receive corn and lima beans for the lunch meal, but she got them anyway. Interview with Dietary Cook 3 on (MONTH) 3, (YEAR), at 12:55 p.m. confirmed that a note was sent to the dietary department, but she did not see or read it and assumed that Resident 9 wanted everything on her plate. A comprehensive admission MDS assessment for Resident 4 dated (MONTH) 25, (YEAR), revealed that the resident was cognitively impaired, was not able to express her needs, and was able to eat independently after set-up. Review of Resident 4's dietary meal ticket on (MONTH) 3, (YEAR), revealed that the resident disliked eggs and cream of wheat. Observation of Resident 4's breakfast meal on (MONTH) 3, (YEAR), at 7:50 a.m. revealed that the resident received eggs and cream of wheat on her meal tray. Interview with Licensed Practical Nurse 4 on (MONTH) 3, (YEAR), at 7:50 a.m. confirmed that Resident 4's dietary meal ticket indicated that she disliked eggs and cream of wheat, and the resident should not have received these items on her breakfast tray. A comprehensive admission MDS assessment for Resident 5, dated (MONTH) 25, (YEAR), revealed that the resident could express her needs and could eat independently after set-up. Review of Resident 5's dietary meal ticket on (MONTH) 3, (YEAR), revealed that the resident disliked coffee. Observations of Resident 5's breakfast tray on (MONTH) 3, (YEAR), at 7:05 a.m. revealed that the resident was served coffee on her tray. Interview with Resident 5 at that time confirmed that she disliked coffee and found it to taste bitter. An interview with the Nursing Home Administrator on (MONTH) 3, (YEAR), at 2:20 p.m. confirmed that the dietary department continued to have a problem related to listing allergies and following residents' meal tickets. She also confirmed that both medication and food allergies should be included on each resident's allergy list and that resident's care plans should include allergy interventions. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(3)(5) Nursing services. Previously cited 1/5/18, 1/26/17