Every finding on record at Willowcrest

Based on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: Observations conducted on December 29, 2025, at 9:56 a.m. with the Food Service Director (FSD), Employee E4, and Chef, Employee E5, in the main kitchen revealed food items were improperly labeled, undated, uncovered, or stored in a manner that could lead to contamination. Observations in the main refrigerator revealed blue cheese (2lbs- pounds) that was undated and additional 3 lbs. without a use-by-date; 3lbs of Monterey [NAME] cheese with no date; 5 lbs. [NAME] cheese with use-by dates of 12/12 and 12/30; 5lbs [NAME] cheese that was undated; mild cheddar slices that were opened, exposed, and undated; and Swiss cheese that was opened and undated. Continued observation revealed three 4-8 lb. bags of beef vegetable soup without thaw or pull dates, and approximately 70 lbs. of roast beef (10 pieces) were observed stored uncovered. Raw turkey was observed leaking red fluid and was undated. Continued observations of the main freezer revealed shrimp with ripped-open packaging and exposed product, with freezer burn present. The shrimp was stored on the lowest rack, with poultry stored above it and beef stored above vegetables, creating a risk for cross contamination. Interview with the Food Service Director, Employee E4, and Chef, Employee E5, throughout the kitchen tour confirmed the above-mentioned findings. 28 Pa. Code 201.14(a) Responsibility of licensee

Based on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to review and revise a resident care plan with new interventions status prior and post a fall incident for one of 12 residents reviewed (Resident R24).Findings include:Review of facility policy titled Resident Assessment and Plan of Care revised July 2018 states the process of systematically reviewing a resident's physical functional mental and psychological status to identify strengths and weaknesses for which the interdisciplinary team can develop a plan of care for each resident. Review of the November 20, 2025, therapy note assessed Resident R24 with impairments and limitations with the resident's ADL's (activities of daily living), bed mobility, cognitive, decreased knowledge of condition, decreased knowledge of precautions, and safety awareness. Therapist noted that the resident tended to favor the resident's left side (weak side). To incorporate bed mobility and safe positioning in bed, the nursing staff were notified to use a wedge pillow with dycem mat positioned on the left side in bed and fall mat on the resident's right side.Review of Resident R24's care plan was not revised and updated to include these new interventions. Further review of Resident R24's clinical record revealed that on December 9, 2025, nursing note indicated that Resident R24 was in bed using the bed pan and the resident fell out of the bed onto the floor. During an interview with the Director of Nursing (DON), Employee E2 on December 31, 2025, at 11:00 a.m. stated that after the fall the new intervention was for the staff to stand nearby while being toileted. Further review of Resident R'24's care plan revealed the facility failed to develop and implement interventions in accordance with the resident's assessed needs, goals for care, and failed to recognize standards of practice that addressed Resident R24's identified limitations and revised the care plan appropriately. Interview with the DON, Employee E2 on January 2, 2026, at 10 a.m. confirmed there was no documented evidence that the facility reviewed and revised Resident R23's care plan based upon the therapist assessment and failed to address new interventions that related to the residents fall. 28 Pa. Code 211.10 (d) Resident care policies.

Based on review of facility policy, review of clinical records, and staff interview, it was revealed that the facility failed to assess and implement interventions to ensure acceptable parameters of nutritional status for one of 2 residents reviewed for nutrition (Resident R16). Findings include: Review of facility policy, Height and Weight Protocol dated January 1, 2025, revealed that upon admission, residents' weight and height will be recorded and residents with a weekly weight gain or weight loss of five pounds will be re-weighed. Review of Resident R16's clinical records revealed that on December 12, 2025, the resident's admission weight was documented as 94 pounds. A follow-up interview conducted on January 2, 2026, at 11:20 a.m. with Registered Dietitian (RD), Employee E3, revealed that the admission weight of 94 pounds was not transcribed into the system and was therefore not referenced by the nutrition services team when assessing Resident R16's weight changes. Continued record review revealed that on December 17, 2025, Resident R16's weight was documented as 104.7 pounds, representing an 11.38% (or 10.7 pound) weight gain in five days when compared to the admission weight. Despite this significant weight gain, continued review of the medical record and interview with the RD, Employee E3, conducted on January 2, 2026, at 11:25 a.m. confirmed that no reweight was completed after December 12, 2025, to validate the accuracy of the weight, and the significant weight change was not addressed or evaluated by the nutrition services team. Continued review of clinical records for Resident R16 failed to reveal evidence of reconciliation of the significant weight gain or confirmation of accurate baseline weights. Follow-up interviews with Registered Dietitians, Employee E3 and RD Employee E4, conducted on January 5, 2026, at 11:30 a.m. confirmed failure to identify and investigate the significant conflicting weight change, and to ensure accurate weights were used to guide nutritional assessment and interventions for Resident R16. 28 Pa. Code 211.5 (f) Clinical records 28 Pa. Code 211.6 (d) Dietary services 28 Pa. Code 211.12 (c)(5) Nursing Services

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in the language and manner they understood for one of three closed records reviewed (Resident R50).Findings include: Review of Resident R50's medical records revealed that on December 11, 2025, the resident was admitted to the hospital for shortness of breath. Continued review failed to reveal documentation of a written notification to the residents or resident's representative notifying them of the transfer and the reasons for the move in writing. Interview with the facility administrator, Employee E1 on January 5, 2026, at 1:00 p.m. confirmed this finding. Continued interview with the facility administrator, Employee E1 on January 5, 2026, at 1:05 p.m. confirmed the above-mentioned findings and stated that it is not facility practice providing the residents and/or their representative with a written notice for transfers. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights

Based on review of resident clinical records, facility documentation and interview with staff, it was determined that the facility failed to ensure an incontinent resident who was unable to carry out activities of daily living received the appropriate services with toileting for one of 12 resident records reviewed (Resident R24).Findings include: Review of Resident R24's occupational therapy (OT) assessment notes dated November 20, 2025, revealed the resident was admitted to the facility on [DATE], with a history of traumatic intracranial hemorrhage (bleeding in the brain), right Middle Cerebral Artery (aka MCA stroke) in October 2025 which left the resident with left residual weakness and left sided body pain. The therapist assessment indicated the resident's impairments included impaired safety/judgment, and functional communication impairments, that included Dysarthria, (speech disorder leading to slurred or low speech) and aphasia (a language disorder caused by brain damage). The same assessment noted Resident R24 with complaints of leg pain and increased pain 10 out of 10 after gentle stretching when therapist positioned the residents lower left leg in relation to bed mobility while cleaning and diaper changing in bed. Physical Therapy note dated November 19, 2025, assessed the resident as dependent with bed mobility, rolling, going from sitting to lying and lying to sitting on the edge of bed required the assistance of 2 or more helpers. The same note noted the resident had profound left side pain to light touch and pressure when rolling, scooting, and repositioning in bed. Details of the speech therapy note dated December 4, 2025, stated Resident R24 was seen up in a wheelchair, grimacing, fidgeting appeared in pain. The therapist attempted to have the resident use the call button to request help but required repositioning of call button two times to accurately grip and call. Speech therapy note dated, December 9, 2025, indicated the resident appeared in pain and needed repositioning. Nursing Aide (NA) Employee E8 re-adjusted the resident to improve the resident's positioning and comfort. The resident later in the note told the therapist, the resident needed to use the toilet and wanted to use the bathroom. The therapist indicated that Nurse aide Employee E8 told the therapist that the resident could Go and be changed after. The therapist noted that Nurse aide, Employee E8 put the resident on the bedpan at end of the session. Immediately after, a nursing progress note indicated the resident was in bed using the bed pan at that time and fell out of the bed, onto the floor. During an interview on January 5, 2026, at 10:00 a.m. with Employee E8 explained that when the therapist told the Nurse aide, Employee E8 the resident needed to go to the bathroom, to the Nurse aide, Employee E8, it appeared to be an emergency, so she said she went to get the bedpan. The NA said by the time she came back with the bedpan the therapist had already left. Surveyor asked the NA if the resident normally uses the bedpan when toileted. NA replied, No, and it confused me because she is incontinent. I would normally just change her after she soiled her brief. I put her on the bedpan by myself. She was crying out in pain when I was trying to sit her upright on the bedpan. Every little movement normally hurts the resident, and she moans a lot in pain. I left her for 5-10 minutes with the call bell on her stomach. She was still making moaning sounds like she was uncomfortable on the bedpan when I left. After 5-10 minutes I came back and heard she was on the floor. January 5, 2026, at 10:30 a.m. during an interview with Resident R24's son stated he went to see the resident immediately after the fall. He told the surveyor she wasn't hurt but she repeatedly said to him, 'Bedpan hurt, bedpan hurt.' Interview with the Director of Nursing (DON) on January 5, 2026, at 11:00 a.m. indicated he was one of the first staff members in Resident R24's room after the fall. The DON stated the resident was attempting to get off the bedpan herself. The resident told the DON she could not find the call bell, but the DON did notice it was hanging off the bed after the fall. 28 Pa. Code 211.10 (d) Resident care policies28 Pa code 211.12.(d)(1)(5) Nursing services

Based on the review of clinical records and interviews with staff, it was determined that the facility failed to ensure care and treatment were provided in accordance with physician orders for one of 12 residents reviewed. (Resident R3)Findings Include: Review of resident R3's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including fractures, foot drop (inability lifting the front part of the foot). The resident was assessed with a BIMS (Brief Interview of Mental Status) score of nine, indicating moderate cognitive impairment. Continued review of Resident R3's clinical records revealed a physician order dated December 1, 2025, for multipodus boots to left foot drop (orthopedic positioning boots used to protect and properly align the foot and ankle). The physician order failed to indicate parameters for use, including duration, timing, and conditions for use of the mulitpodus boots. Interview conducted on December 30, 2025, at 11:20 a.m. with registered Nurse, Employee E6, revealed that the resident was not wearing the ordered boots because she doesn't like them, and the nurse was unfamiliar with specific order details or when the boots were to be applied. Observations conducted on December 30, 2025, revealed the resident at bedside wearing a sneaker and leg brace, with no multipodus boots present in the room or readily available. Interview with the Physical Therapy Manager, Employee E7, conducted on January 5, 2026, at 9:51 a.m. revealed the resident was using a leg brace and sneaker as part of a therapy trial; however, Employee E7 was unsure of the specific physician order requirements related to the multipodus boots. Follow-up interview with Physical Therapy Manager, Employee E5 via electronic communication, confirmed that the multipodus boots were intended to be worn at night, according to the physician. Further review of clinical record failed to reveal documentation that the resident was provided or wore the multipodus boot at any time. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to Respiratory Precautions for one resident on respiratory precaution of seven residents reviewed (Resident R122). Findings include: Review of facility policy on Enhance Respiratory Precaution reveled that under section PURPOSE: To prevent transmission of emerging or highly pathogenic infections spread by means of respiratory route. Under section POLICY: Any patient known or suspected to have an infection with an emerging or highly pathogenic organism that may be transmitted by means of the respiratory route shall be placed on Enhanced Respiratory Precaution. Section GENERAL SCOPE OF PRACTICE: #D. Personal Protective Equipment (PPE); Prior to entering the room, staff shall perform hand hygiene and then don appropriate respiratory protection (N95- a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles or PAPR-Powered Air Purifying Respirator), isolation gown, gloves and eye protection. prior to exiting the room, staff shall remove gown and gloves and perform hand hygiene. Review of Resident R122's clinical record revealed that Resident R122 was admitted to the facility on [DATE], with diagnoses of but not limited to: COVID+, Hemiplegia/Hemiparesis, Diabetes Mellitus. Medication observation conducted on January 29, 2025 at 8:55 a.m. with licensed nurse, Employee E3 for Resident R122 revealed that Resident R122 had a diagnoses of covid19 and was in and enhanced respiratory precaution. Further observation revealed that the door to Resident R122's room had a signage for Red Zone and Signage for Enhanced Respiratory Precaution with instructions on the signage as follow: hand Hygiene, N-95 or PAPR, Eye/Face protection, Gown and gloves, dedicated disposable equipment, disinfect reusable equipment. Further observation revealed that while outside Resident R122's room (Room # 305), Employee E3 donned, gown, gloves and N-95 mask, and proceeded to go inside Resident R22's room and spoke with Resident R122. Further observation revealed that Employee E3 came out of Resident R122's room wearing the N-95, gown and gloves. She proceeded to remove the gloves and discard it in the garbage bin attached to the medication cart which was parked outside of Resident R122's room. Further, Employee E3 did not remove the gown. Employee E3 then proceeded to prepare Resident R122's medication, while standing outside of Resident R122's room still wearing the PPE's that she wore inside Resident R122's room. Further observation revealed that after preparing the medications for Resident R122, Employee E3 then walked towards Room # 304 which was next to Resident R122's room, still wearing the same gown she wore inside resident R122's room and proceeded to take gloves which were in a bin on the wall located outside the door or Room # 304. Employee E3 then donned the gloves, walked back towards the medication cart, proceeded to take the medications that she prepared and went inside Resident R122's room and administered her medications. Interview with the Licensed nurse, Employee E3 conducted after she came out of the room confirmed that she did not remove and discard the gown when she entered Resident R122's room and that she continued to wear the same gown while prepping the medications and walking in the hallway to get a clean pair of gloves. Interview with Infection control manager, Employee E4 and Infection Control Nurse, Employee E5 conducted on January 29, 2025 at 10:26 am during infection control interview revealed that staff must don N-95 mask, eye protection, surgical gown and gloves prior to entering a room occupied by a patient on Enhanced Respiratory Precaution, and that staff must remove and discard the gown and gloves, before exiting the room. 28 Pa Code 201.14(a) Responsibility of licensee 28 Pa Code 201.18(d) Management

Based on observation, resident group interview, and staff interview, it was determined that the facility failed to ensure that grievance forms were available and accessible to residents and failed to provide an opportunity for anonymous grievances to be submitted for three of three residents reviewed. (Reisdents R76, R80 and R125) Findings include: Review of facility policy titled Grievance Policy for Residents and Resident Representatives, dated 2017, revealed each resident has the right to voice grievances and recommend changes for improvement to staff, administration, or outside representative of his/her choice, without discrimination or reprisal. Also, a prominent posting will be located in the lobby and 3rd floor with Grievance Official contact information. A resident group interview was conducted on January 28, 2025 at 11:04 a.m. with Residents R76, R80, R125, who were alert and orientated, and reported that they did not know how to file grievances anonymously and do not know where the grievance forms are located. Observation on the 3rd floor revealed no grievance forms or grievance box available or accessible to residents. Interview on January 28, 2025 at 12:50 p.m. with Employee 6, Unit Coordinator, revealed resident grievance forms were located in the filing cabinet that was only accessible to employees and there was no grievance box on unit for residents to submit grievances anonymously. 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(a) Resident rights

Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow the physician orders related to medication administration for one of 3 residents reviewed (Residents R1). Findings include: Review of Resident R1's clinical record indicated admitted [DATE], and had diagnoses including ventricular tachcardi (is a type of abnormal heart rhythm (arrhythmia) characterized by a rapid heartbeat originating from the heart's lower chambers, the ventricles), coronary artery disease (cad) (condition characterized by the narrowing or blockage of the coronary arteries, which supply oxygen-rich blood to the heart muscle), heart failure, atrial fibrillation, (which is the most common type of heart arrhythmia). Review of physician orders indicated that Resident R1 was prescribed Melatonin 9 milligrams (mg) one a day in the evening on January 29, 2024 Interview conducted on February 8, 2024, at 10:12 a.m. with License nurse, unit manager, Employee E5 confirmed that the facility policy for medication administration was the following: Morning medication 9:00 a.m. and administered one hour prior or after. Afternoon medication 5:00 p.m. and could be administered one hour prior or after. Night Medications: 9:00 p.m. and could be administered one hour prior or after. Review of Resident R1's February 2024 Medication Administration Record with License nurse, unit manager Employee E5 revealed that Melatonin 9 mg was not administered to the resident during the evening shift on February 4, 2024, and there was no reason documented for not administering the medication. On February 8, 2024, at approximately 11:00 a.m. an interview was conducted with License nurse, Employee E4 who was assigned to Resident R1 on February 4, 2024, during the evening shift and reported that Melatonin medication was out, and she placed an order to the pharmacy. This was not documented in the clinical file. Facility receives medication on daily bases from the pharmacy to be administered for Resident R1. On February 20, 2024, at 2:48 p.m. a telephone interview was conducated with the pharmacist, Employee E6 who confirmed that the facility did not electronically request this medication on February 4, 2024. It further revealed that facility did have Accudose grab machine stored in their medication room on the unit which has frequent medication supply and Melatonin was one of the medications that pharmacy stores for Accudose grab machine. Further clinical records reviewed that Resident R1 had a physician order on January 30, 2024, to received Hydrolazine 50 mg every 8 hours. Review of January 2024 Medication Administration Report (MAR) revealed this medication was not given on January 31, 2024, at 1:00 p.m. License Nurse unit manager, Employee E3 reported on February 8, 2024 at approximately 11:00 a.m. that she was assigned to the cart and unsure why the medication was not administered. There was no documentation in the clinical record to document the reason for a missing medication. Further clinical record review indicated a physician order obtained January 29, 2024, for Amiodarone 200 mg daily once a day. This medication was administered on January 30, 2024, at 10:10 a.m. by the License nurse, Unit Manager, Employee E5 who had to step in as there was a call out on the cart; therefore, the medication was late. On February 8, 2024, at approximately 2:30 p.m. [NAME] President, Employee E1 and Medical Director, Employee E6 both confirmed above medications were not administered based on the physician order. 28 Pa Code 211.12(d)(5) Nursing services

Based on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure residents were adequately informed and educated regarding how to receive alternate food choices, how to request condiments to complement their meals, and rationale that facility staff may therapeutically substitute foods chosen by a resident, for seven of seven residents interviewed (Residents R77, R85, R92, R93, R94, R95 and R132). Findings include: During the Resident Council Interview with seven alert and oriented residents (Residents R77, R85, R92, R93, R94, R95 and R132) on (MONTH) 16, 2019, at approximately 1:30 p.m., the residents stated that they are provided with a paper menu to be filled out on a daily basis, that a staff member collects their completed menu daily, and that the menu completed by each resident is for the next day's meals (breakfast, lunch and dinner). The residents unanimously stated that they were not aware that the facility offered alternate food items if the main menu items did not suit the resident's preference during each meal, and that this information is not included on the paper menu provided to them daily. The residents also stated that if they did not specifically designate on their paper menu that they wanted condiments to complement their meal (salt, pepper, ketchup, mustard, mayonnaise, etc.), they did not automatically receive condiments and if they asked staff for condiments as they received their meal tray, there were none readily accessible on the nursing unit. One resident clarified that as an example, he/she recently received a hamburger and then decided after the hamburger was delivered that he/she wanted mustard to put on the hamburger. The resident asked staff for mustard and since there were no mustard packets on the unit, the resident ate the hamburger without mustard, because it would take too long to get mustard from the main kitchen and my burger would be cold by the time I got the mustard. Additionally, the seven residents indicated that there were times that they did not always receive what they ordered on their menu, and that substitutions and/or omissions were made by the kitchen staff without their choice or input. Observation of the nursing unit pantry on (MONTH) 17, 2019, at approximately 8:40 a.m., in the presence of Employee E3, nursing unit manager, revealed the following food items: pantry cabinet contained an assortment of single-serve cold cereals each in plastic disposable bowls (Rice Krispies, Cinnamon Toast Crunch, Total, Frosted Flakes and Corn Flakes); pantry drawer contained one plastic basket with saltine cracker packets (two crackers per packet) and one plastic basket containing packets of sugar, packets of Splenda no-calorie sweetener, and packets of nondairy powder creamer. In the pantry refrigerator were: several cups of single-serve applesauce and several cups of single-serve orange gelatin dessert. In the pantry freezer were: several single-serve chocolate ice cream containers and several single-serve vanilla ice cream containers. Further observation of the nursing unit pantry revealed no other snack items were present (ex. peanut butter crackers, graham crackers, cookies or sugar-free cookies, pretzels) and no other condiments (ex. ketchup packets, mustard packets, mayonnaise packets, salt packets, pepper packets, salt-substitute packets). Interview with Employee E4, Food Service Director, on (MONTH) 17, 2019, at approximately 11:30 a.m. revealed that upon a resident's admission to the unit, a pamphlet is provided to each resident that describes the services provided by the Food and Nutrition Department. Review of the pamphlet titled, Treat Yourself Directory of Services, dated (MONTH) (YEAR), included information such as, How do I get a menu?; Why are there food items removed or added to my trays? and, During your stay the physician may order a modified diet for you. This is to help with your recovery. Such diets as low sodium (salt), low fat (heart healthy) or carbohydrate controlled (diabetic) may be ordered. Your menu may be different from your roommate or even change during your stay at Willowcrest. The interview also revealed that after each resident completes their menu, this information is placed in the facility's dietary computer system in order for the meals to be prepared for the next day. Further interview with Employee E4 revealed that the facility has an Or You (MONTH) Prefer menu (food items that are always available) with multiple choices for alternative food items, but these selections are not listed on the Treat Yourself Daily Dining Menu (menu that residents fill out on a daily basis). Review of facility handout, Or You (MONTH) Prefer indicated multiple alternative food items were listed, including carbohydrate controlled (limit the amount of starchy foods that can elevate blood sugar levels in the blood) diet options. Further interview with Employee E4 revealed that if a resident is on a prescribed carbohydrate controlled diet, there are only so many carbohydrate food choices that are allowed during each meal and that if a resident circles/chooses more than the allowable number of carbohydrate items per meal, the facility's computer software program will automatically remove certain choices (without notifying the resident that there were too many carbohydrate foods chosen on a particular meal, and without allowing the resident to reevaluate what choices they may prefer instead of the computer choosing for them). Observation on (MONTH) 17, 2019, at approximately 1:30 p.m. of the nursing unit hallway including rooms 316-328 revealed one copy of the Or You (MONTH) Prefer handout, measuring approximately 4.5 inches by 11 inches, hanging on a bulletin board across from resident room [ROOM NUMBER]. This handout, printed on white paper with muted green and black lettering, was not easily visible or noticeable to passersby. Interview with Employee E5, Registered Dietitian, on (MONTH) 20, 2019, at approximately 10:20 a.m. revealed that every resident is assessed by a facility dietitian within 24 hours of their admission, and that each resident's prescribed diet, along with the Treat Yourself Directory of Services, pamphlet, is reviewed with the resident at that time. Further interview with Employee E5 revealed that after admission, however, there was no established process in place to review this information again in case a resident was in pain, ill, or not in the proper frame of mind during the admission process to understand and retain all of the diet/menu/choice options that were provided upon initial admission. The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on (MONTH) 17, 2019, at approximately 2:00 p.m. and at approximately 12:00 p.m. on (MONTH) 20, 2019. The facility failed to ensure each resident was reasonably accommodated and educated on prescribed diet, availability of food alternatives, and accessibility of food condiments. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/21/18, 08/31/18, 06/02/17 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.6(c) Dietary services

Based on observations, review of facility policies and procedures and facility documentation, and interviews with residents and staff, it was determined that the facility failed to offer a nourishing snack for residents at bedtime, for seven of seven residents interviewed (Residents R77, R85, R92, R93, R94, R95 and R132). Findings include: During entrance conference with the Nursing Home Administrator on (MONTH) 15, 2019, at approximately 9:15 a.m., the facility's census at the time of entrance was 37 residents, with maximum bed capacity of 44 residents. During the Resident Council Interview with seven alert and oriented residents (Residents R77, R85, R92, R93, R94, R95 and R132) on (MONTH) 16, 2019, at approximately 1:30 p.m., the residents unanimously stated that they were not consistenly offered an evening snack every night. The seven residents indicated that residents with diabetes (diabetes mellitus-failure of the body to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment) or other health problems get a labeled snack from the facility's kitchen (ex. half of a sandwich labeled with a specific resident's name on the wrapped sandwich), but that unless you're diabetic, nobody else gets snacks. Observation of the nursing unit pantry on (MONTH) 17, 2019, at approximately 8:40 a.m., in the presence of Employee E3, nursing unit manager, revealed the following food items: pantry cabinet contained an assortment of single-serve cold cereals each in plastic disposable bowls (Rice Krispies, Cinnamon Toast Crunch, Total, Frosted Flakes and Corn Flakes); pantry drawer contained one plastic basket with saltine cracker packets (two crackers per packet). In the pantry refrigerator were: several cups of single-serve applesauce and several cups of single-serve orange gelatin dessert. In the pantry freezer were: several single-serve chocolate ice cream containers and several single-serve vanilla ice cream containers. Further observation of the nursing unit pantry revealed no other snack items were present (ex. peanut butter crackers, graham crackers, cookies or sugar-free cookies, pretzels). Interview with Employee E3 at the time of the observation on (MONTH) 17, 2019, revealed there was no established process in place to ensure staff on the 3:00 p.m. to 11:00 p.m. shift offered and distributed snacks to every resident every night (except for labeled/physician-ordered snacks). Review of facility policy, Special Food Requests-PM (evening) Bulk Snacks-Willowcrest, dated last reviewed (MONTH) 12, 2019, revealed that a bulk snack supply would be provided to the nursing unit from the dietary kitchen every evening using a seven-day snack rotation cycle. The policy further indicated that every evening at the time meal trucks are delivered to distribute the evening meal, dietary staff would deliver the bulk snacks for the evening and that nursing staff would be responsible for delivering the bulk snacks to the residents after dinner and prior to bedtime. Review of facility document, Willowcrest Bulk Snack Rotation, dated revised (MONTH) 16, (YEAR), revealed the following snacks and quantities are delivered to the nursing unit each day. Mondays: 25 one ounce bags of pretzels, and 4 single-serve containers of applesauce (total of 29 snacks for the floor) Tuesdays: 20 packs of peanut butter crackers (4 per pack/serving), and 4 single-serve containers of pudding (total of 24 snacks for the floor) Wednesdays: 12 single-serve containers of ice cream (total of 12 snacks for the floor) Thursdays: 15 chocolate chip or oatmeal cookies (2 per pack/serving), 5 diet cookies, and 4 single-serve containers of pudding (total of 24 snacks for the floor) Fridays: 15 chocolate chip or oatmeal cookies (2 per pack/serving), 5 sugar-free cookies, and 4 single-serve containers of applesauce (total of 24 snacks for the floor) Saturdays: 15 chocolate chip or oatmeal cookies (2 per pack/serving), and 4 single-serve containers of pudding (total of 19 snacks for the floor) Sundays: 15 peanut butter cracker packets (4 per pack/serving), and 4 single-serve containers of applesauce (total of 19 snacks for the floor) Review of undated facility document, Floor Supplies: Willow Crest, revealed that the par level (amount that the unit should have on a daily basis) for graham crackers (2 per pack) are 10; saltine crackers (2 per pack) are 10; and salt-free crackers are 10 (2 per pack). Further review of the Willowcrest Bulk Snack Rotation, and Floor Supplies: Willow Crest, lists revealed the snack quantities allocated by the facility would not be enough to offer an evening snack to each of the 37 residents in the facility during the survey, and to each of 44 residents if the unit was full to maximum capacity (excluding any physician-ordered snack for medical reasons). The facility failed to ensure each resident was offered a suitable and nourishing snack every night at bedtime, and that the unit had enough snacks on hand to offer a snack to everyone on the unit. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/21/18, 08/31/18, 06/02/17 28 Pa. Code 201.29(j) Resident rights 28 Pa. Code 211.6(c) Dietary services

Based on observations, review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that residents were assessed for safe self-administration of medications, for one of 16 resident records reviewed (Resident R88). Findings include: Review of facility policy, Self-Administration of Medication, dated effective (MONTH) 14, (YEAR), revealed that upon written permission of the physician and assessment by the interdisciplinary team, a resident may self-administer prescription medications. Observation during initial tour of the facility on (MONTH) 15, 2019, at approximately 9:45 a.m. revealed an [MEDICATION NAME] (inhaled medication used to open the airways for persons with asthma-disease of the airways of the lungs that causes wheezing, tight chest and shortness of breath) MDI (metered-dose inhaler) located on Resident R88's overbed table. Additional observation on (MONTH) 16, 2019, at approximately 11:45 a.m. revealed the same [MEDICATION NAME] MDI located on Resident R88's overbed table. Review of the clinical record for Resident R88 revealed the resident was admitted to the facility on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Further review of the clinical record for Resident R88 revealed no documentation that the resident was assessed by the interdisciplinary team to determine if the practice was safe (resident is completent in self-administration of medications). Interview with the Director of Nursing on (MONTH) 20, 2019, at approximately 9:05 a.m. confirmed there was no documenation that Resident R88 was assessed by the interdisciplinary team to evaluate the resident's ability to safely self administer medications, and confirmed there was no documentation that a physician's orders [REDACTED]. The facility failed to assess a resident for safe self-administration of medication. 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/21/18, 08/31/18, 06/02/17 28 Pa. Code 201.18(e)(1) Management Previously cited 12/21/18, 08/31/18 28 Pa. Code 211.10(d) Resident care policies Previously cited 12/21/18, 08/31/18, 06/02/17 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/21/18, 08/31/18, 06/02/17

Based on observation, review of clinical records and interviews with staff, it was determined that the facility failed to develop a comprehensive person-centered care plan, with measurable objectives and goals related to respiratory disorders, for one of 16 resident records reviewed (Resident R88). Findings include: Observation during initial tour of the facility on (MONTH) 15, 2019, at approximately 9:45 a.m. revealed an [MEDICATION NAME] (inhaled medication used to open the airways for persons with asthma-disease of the airways of the lungs that causes wheezing, tight chest and shortness of breath) MDI (metered-dose inhaler) located on Resident R88's overbed table. Additional observation on (MONTH) 16, 2019, at approximately 11:45 a.m. revealed the same [MEDICATION NAME] MDI located on Resident R88's overbed table. Review of the clinical record for Resident R88 revealed the resident was admitted to the facility on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Further review of the plan of care for potential altered airway exchange for Resident R88 revealed no documentation to include the resident's [DIAGNOSES REDACTED]. Interview with the Director of Nursing on (MONTH) 20, 2019, at approximately 11:15 a.m. confirmed that the care plan for Resident R88's respiratory status was not comprehensively developed related to the use of inhaled medication to treat the resident's [DIAGNOSES REDACTED]. The facility failed to ensure that a comprehensive person-centered care plan was developed for one resident with a [DIAGNOSES REDACTED]. CFR(s): 483.21(b)(1) Develop/Implement Comprehensive Care Plan Previously cited 06/02/17 28 Pa. Code 201.14(a) Responsibility of licensee Previously cited 12/21/18, 08/31/18, 06/02/17 28 Pa. Code 201.18(e)(1) Management Previously cited 12/21/18, 08/31/18 28 Pa. Code 211.11(a)(b) Resident care plan 28 Pa. Code 211.11(c) Resident care plan Previously cited 12/21/18 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/21/18, 08/31/18, 06/02/17

Based on review of clinical records and interviews with staff, it was determined that the facility did not maintain complete and accurate clinical records for one of 16 residents' records reviewed (Resident R81). Findings include: Review of Resident R81's clinical record revealed that the resident was admitted to the facility from an acute care hospital on (MONTH) 3, 2019 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review of the clinical record revealed that on (MONTH) 10, (YEAR) the physician ordered resident's diet to be changed to chopped (food to be cut by hand into even bite size pieces) low sodium diet. Further review of Resident R81's clinical record revealed that a weight of 64.8 kilograms (142.5 pounds) was documented on (MONTH) 4,2019, and the same weight of 64.8 kilograms was documented on (MONTH) 8, 2019. Further review of the clinical record revealed that on (MONTH) 12, 2019 the resident's weight was documented as 54.6 kilograms (120.1 pounds) which indicated a weight loss of 10.2 kilograms (22.4 pounds) or 15.4%, indicating a significant (very serious) weight loss. Documentation in the clinical record also revealed an additional, second weight documented for (MONTH) 12, 2019 as 54.6 kilograms (120.1 pounds). Additional weights documented in the clinical record were 55.4 kilograms (121.9 pounds) on (MONTH) 13, 2019, and 53.5 kilograms (117.7 pounds) on (MONTH) 15, 2019. Review of the clinical progress notes of (MONTH) 16, 2019 revealed documentation by Employee E5, dietician, that stated the admission weight (May 4, 2019) was an estimated weight for Resident R81, and not the actual weight of the resident. The same clinical progress note indicated that Employee E5, the dietician, reweighed the resident on (MONTH) 16, 2019 and confirmed a 58.3 kilograms (128.3 pounds), which was as 111% of the resident's ideal body weight. Interview with the Nursing Home Administrator on (MONTH) 16, 2019, at approximately 11:00 a.m. confirmed that the documentation of Resident R81's weights were not accurate. The facility failed to maintain complete and accurate clinical documentation related to weights for one resident. 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 12/21/18, 08/31/18, 06/02/17 28 Pa. Code 211.5(f) Clinical records Previously cited 12/21/18, 08/31/18, 06/02/17 28 Pa. Code 211.5(h) Clinical records

Based on a review of facility policies and procedures, medical record review and staff interview, it was determined that the facility failed to develop a comprehensive baseline care plan for three of nine residents identified as a high risk of falling (Residents R1, R2 and R3). Findings include: Review of a facility policy titled Fall Risk Assessment, Prevention, and Management of a Resident Post Fall effective 4/14/17 revealed that when a resident is deemed at risk for falls the facility will initiate the Fall Prevention Program including adding fall risk to the care plan. Review of the medical record for Resident R1 revealed that the resident was admitted to the facility on (MONTH) 12, (YEAR), and was assessed as being a high risk for falls upon admission. Further review of the medical record revealed there was no baseline care plan for falls prevention available for review to increase the resident's safety. Documentation revealed that Resident R1 sustained a fall on (MONTH) 19, (YEAR) and no fall interventions had been developed. Review of the medical record for Resident R2 revealed that the resident was admitted to the facility on (MONTH) 1, (YEAR), and was assessed as being a high risk for falls upon admission. Further review of the medical record revealed that a safety protocol plan was included in the resident's care plans; however, the fall protocol was not included as one of the implemented plans to increase the resident's safety. Review of the medical record for Resident R3 revealed that the resident was admitted to the facility on (MONTH) 17, (YEAR), and was assessed as being a high risk for falls upon admission. Further review of the medical record revealed there was no baseline care plan for falls prevention available for review to increase the resident's safety. Interview on (MONTH) 6, (YEAR), at 2:31 p.m. with Employee E2, Director of Nursing, revealed confirmation that fall prevention care plans had not been developed or implemented for Residents R1, R2 and R3. The facility failed to develop comprehensive person-centered care plans for three residents at risk of falling. 28 Pa. Code 211.5(f) Clinical Records. Previously cited 8/31/18, 6/2/17, 5/5/16 28 Pa. Code 211.11(c)(d) Resident Care Plan. 28 Pa. Code 211.10(d) Resident Care Policies. Previously cited 8/31/18, 6/2/17, 5/5/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. Previously cited 8/31/18, 6/2/17, 5/5/16

Based on a review of clinical records and staff interview, it was determined the facility failed to provide timely care, to assess and to monitor a resident according to physician orders [REDACTED]. Findings include: Review of a facility policy titled Fall Risk Assessment, Prevention, and Management of a Resident Post Fall effective 4/14/17 revealed under section IV C. Implementation of Post Fall Care that the healthcare provider who discovers a resident post-fall must remain with the resident until further assistance arrives. The post-fall assessment involves assessment of potential injury, vital signs and pulse oximetry, neurological checks when conditions warrant, finger stick blood glucose testing when conditions warrant and reassessment using the Morse Fall Scale. The implementation of post-fall care also includes notifying the nursing supervisor, interdisciplinary care team and rehabilitation team as appropriate, implement physician/designee orders as needed and implement Fall Prevention Intervention as appropriate. Review of facility documentation for a fall that occurred at 12:00 p.m. on (MONTH) 23, (YEAR), involving Resident CL1 revealed as stated, Physical Therapy notified nursing that patient was found on the floor. Patient able to stand and was assisted back to bed by therapy and nursing. Patient assessed, vitals obtained; patient alert and oriented times 3 (alert and oriented to place, person and time). Patient reported trying to reach for something and fell , hit front of head. Quarter sized nodule with small abrasion assessed on left side of forehead. Orders to be placed by Nurse Practitioner. Family aware. Review of clinical documentation for Resident CL1 for the results of a CT scan (computed tomography scan uses x-rays to visualize the structures of the head and brain on a computer) revealed, as written, a small left frontal scalp hematoma that was caused by the resident hitting her head when falling. Review of clinical documentation for Resident CL1 revealed a Communication Order placed on (MONTH) 23, (YEAR), at 1:31 p.m. by Employee E5, Medical Doctor (MD), for NEURO CHECK PROT[NAME]OL including vital signs and neurological checks every 15 minutes for one hour (four checks), then every 30 minutes for 1 hour (two checks), then every hour for four hours (four checks) for a total of 10 checks of vital signs and neurological evaluations within the first six hours after the fall. Review of vital signs documentation for Resident CL1 revealed that after the resident's fall on (MONTH) 23, (YEAR), at of Nursing, revealed confirmation that physician orders [REDACTED]. The facility failed to provide timely care to meet one resident's needs and failed to follow physician orders. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 8/31/18, 6/2/17, 5/5/16 28 Pa. Code 201.18(a) Management Previously cited 8/31/18, 6/2/17 28 Pa. Code 201.18(b)(1) Management Previously cited 8/31/18, 6/2/17, 5/5/16 28 Pa. Code 201.18(b)(3) Management Previously cited 8/31/18, 6/2/17 28 Pa. Code 201.18(e)(1) Management Previously cited 8/31/18, 5/5/16 28 Pa. Code 211.5(f) Clinical Records Previously cited 8/31/18, 6/2/17, 5/5/16 28 Pa. Code 211.5(g)(h) Clinical Records Previously cited 8/31/18 28 Pa. Code 211.10(c) Resident Care Policies Previously cited 6/2/17, 5/5/16 28 Pa. Code 211.10(d) Resident Care Policies Previously cited 8/31/18, 6/2/17, 5/5/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services Previously cited 8/31/18, 6/2/17, 5/5/16

Based on a review of facility documentation and interviews with staff, it was determined that the facility did not thoroughly investigate a resident fall for one of five investigation events reviewed. (Resident CL1) Findings include: Review of facility documentation related to a fall that occurred on (MONTH) 25, (YEAR), involving Resident CL1, revealed a statement of a witness to the fall written by Employee E3, Licensed Nurse. The statement indicated that the resident was observed on the floor in front of her wheelchair on her buttocks. Emlpoyee E3 documented that an assessment was completed which indicated that the resident was able to move all extremities and that the resident denied hitting her head. The resident complained of pain to the left leg. Documentation further indicated that Employee E3 and a nursing assistant assisted the resident back into the wheelchair, neuro checks were completed, and the CRNP (Certified Registered Nurse Practitioner) was notified. Documentation from Employee E3 in the witness statement indicated that at least three employees were involved in the event; however only Employee E3's statement was provided by the facility for Resident CL1's fall that occurred on (MONTH) 25, (YEAR). Interview on (MONTH) 6, (YEAR), at 2:31 p.m. with Employee E2, Director of Nursing, revealed confirmation that there should have been three statements for a complete investigation of the fall on (MONTH) 25, (YEAR). The facility failed to complete a thorough invetsigation into a fall sustained by one resident. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 8/31/18, 6/2/17, 5/5/16 28 Pa. Code 201.18(b)(1)(e)(1) Management. Previously cited 8/31/18, 6/2/17, 5/5/16

Based on review of clinical records, facility documentation and interviews with staff, it was determined that the facility failed to provide a safe, hazard free environment and failed to ensure that each resident received adequate supervision for one of 18 residents reviewed resulting in actual harm to one resident who [MEDICAL CONDITION] hot coffee and required being sent to the hospital (Resident 224). Findings include: Review of the clinical record for Resident R224 revealed that the resident was admitted to the facility on (MONTH) 9, (YEAR), with diagnoses, including but not limited to, end stage [MEDICAL CONDITION] (kidney failure). At the time of admission, Resident R224 was noted with an arteriovenous graft (access site) present on the right upper thigh for [MEDICAL TREATMENT] treatments ([MEDICAL TREATMENT]-process of removing waste products and excess water from the body). Continued review of Resident R224's clinical record revealed that the resident was admitted to the facility for physical and occupational therapy. Review of the occupational therapist initial evaluation for Resident R224 dated (MONTH) 10, (YEAR), indicated that the resident required set-up help and assistance for eating. The occupational therapist also indicated that Resident R224's left and right hand grip strength was impaired and/or decreased. The therapist documented that Resident R224's bilateral (both sides) upper extremity strength was impaired with general weakness and pain. The occupational therapist noted that the resident had impaired sensation and coordination in both upper extremities (hands, arms and shoulders). The initial evaluation further indicated that the resident had reported the presence of numbness in both hands. Review of a comprehensive Minimum Data Set assessment (MDS- an assessment of resident care needs) dated (MONTH) 16, (YEAR), indicated that Resident R224 required supervision (oversight, encouragement or cueing) and set-up help (opening milk carton, and condiments) for eating. Review of facility documentation indicated that on (MONTH) 12, (YEAR), at 11:00 a.m. Resident R224 attended a recreational activity program which included the service of hot beverages to residents. Interview with Employee E5, Activities Director, on (MONTH) 31, (YEAR), at 9:15 a.m. confirmed that during this activity Resident R224 was given a cup of hot coffee in a small styrofoam cup. Facility documentation further indicated that Resident R224 spilled hot coffee on both thighs and abdomen during this activities program. It was also confirmed that during this recreational program Employee E5, stepped away from the area/table where Resident R224 and the other residents was seated and drinking their hot coffee. Continued interview with Employee E5 revealed that Resident R224 did not receive set-up help from facility staff with the hot coffee. During the interview Employee E5, further confirmed that supervision of the residents was not provided as Employee E5 had stepped away from the table. Continued review of facility documentation indicated that nursing staff had been notified that Resident R224 had [MEDICAL CONDITION] a coffee spill on (MONTH) 12, (YEAR), at approximately 11:45 a.m. - 11:55 a.m. Facility documentation reflected that nursing staff had assessed Resident R224's right thigh burn and noted a 1 cm. (centimeter) by 0.5 cm area with the skin removed. Facility documentation further indicated that Resident R224 had reported to the registered nurse, that it hurt so bad and rated the pain as an eight (pain rating scale of 0-10; with 0=equals no pain and 10 equals extreme pain). Review of the (MONTH) (YEAR), Medication Administration Record [REDACTED]. The resident was subsequently transferred to the emergency room for further evaluation and treatment at approximately 3:00 p.m., four hours after the burn had occurred. Continued review of facility documentation indicated that the emergency physician examined the resident and determined that the resident had sustained second [MEDICAL CONDITION](partial thickness burn which affects both the upper and lower layers of skin) to the right and left medial (inner) thighs, consistent with a scald wound from hot liquid. The resident was further noted with blistering to the left thigh and a first degree burn (injury to the outer layer of skin caused by heat) to the lower abdomen, following the hot coffee spill. Further review of emergency room physician documentation indicated that the resident should have follow up at a burn clinic. The facility failed to provide an environment free of accident hazards and failed to provide adequate supervision and assistance to prevent accidents for one of 18 residents reviewed, which resulted in actual harm to one resident (Resident R224) who sustained first and second [MEDICAL CONDITION] a hot beverage spill. Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) - Previously cited 06/02/17, 05/0516 28 Pa. Code 201.14(a) Responsibility of license Previously cited 06/02/17, 05/05/16 28 Pa. Code 201.18(a) Management Previously cited 06/02/17 28 Pa. Code 201.18(b)(1) Management Previously cited 06/02/17, 05/05/16 28 Pa. Code 201.18(b)(3) Management Previously cited 06/02/17 28 Pa. Code 201.18(d) Management 28 Pa. Code 201.18(e)(1) Management Previously cited 05/05/16 28 Pa. Code 211.10(a)(b) Resident care policies 28 Pa. Code 211.10(d) Resident care policies Previously cited 06/02/17, 05/05/16 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 06/02/17, 05/05/16 28 Pa. Code 211.12(d)(2) Nursing services

Based on interviews with staff and review of personnel files, it was determined that the facility failed to ensure that a thorough investigation into the background of an out-of-state employee was completed prior to hire for one of five personnel files reviewed (Employee E3). Findings include: Review of the personnel file for Employee E3, Facility Mechanic, who had a date of hire documented as being (MONTH) 7, (YEAR), and lived out of state upon hire, revealed no evidence that additional background checks were completed to ensure that Employee E3 was not found guilty of abuse, neglect, exploitation or mistreatment or misappropriation of property by a court of law. On (MONTH) 31, (YEAR), at approximately 1:00 p.m. it was confirmed by Employee E4, Human Resources Specialist, that Employee E3 did reside out-of-state at the time of his/her hire and had been working at the facility since (MONTH) 7, (YEAR), as a Mechanic II without additional background checks being initiated by the facility. The facility failed to ensure that a thorough investigation into the background of an out-of-state employee was completed. Not Employ/Engage Staff with Adverse Actions CFR(s): 483.12(a)(3)(4) - Previously cited 05/05/16 28 Pa. Code 201.14(a) Responsibility of license previously cited 06/02/17, 05/05/16 28 Pa. Code 201.18(b)(1) Management Previously cited 06/02/17, 05/05/16 28 Pa. Code 201.18(b)(3) Management Previously cited 06/02/17 28 Pa. Code 201.19 Personnel policies and procedures

Based on review of clinical records and interviews with staff, it was determined that the facility failed to immediately notify the resident's physician of a resident injury which resulted in actual harm to the resident and required medical treatment for one of 18 residents reviewed (Resident R224). Findings include: Review of the clinical record for Resident R224 revealed that the resident was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. At the time of admission, Resident R224 was noted with an arteriovenous graft (an access site) present on the right upper thigh for [MEDICAL TREATMENT] treatments ([MEDICAL TREATMENT]-process of removing waste products and excess water from the body). Continued review of Resident R224's clinical record revealed that the resident had been admitted to the facility for physical and occupational therapy. Review of the occupational therapist initial evaluation for Resident R224 dated (MONTH) 10, (YEAR), indicated that the resident required set-up help and assistance for eating. The occupational therapist also indicated that Resident R224's left and right hand grip strength was impaired/decreased. The therapist documented that Resident R224's bilateral (both sides) upper extremity strength was impaired with general weakness and pain. The occupational therapist noted that the resident had impaired sensation and coordination in both upper extremities (hands, arms and shoulders). The initial evaluation further indicated that the resident had reported the presence of numbness in both hands. Review of a comprehensive Minimum Data Set (MDS- an assessment of resident care needs) dated (MONTH) 16, (YEAR), indicated that Resident R224 required supervision (oversight, encouragement or cueing) and set-up help (opening milk carton, and condiments) for eating. Review of facility documentation indicated that on (MONTH) 12, (YEAR), Resident R224 was attending a recreational activity. During an interview with Employee E5, Activities Director, on (MONTH) 31, (YEAR), at 9:15 a.m. it was confirmed that during this activity Resident R224 was given a cup of hot coffee in a small styrofoam cup. Facility documentation further indicated that Resident R224 spilled hot coffee on both thighs and abdomen during this activities program on (MONTH) 12, (YEAR), at 11:00 a.m. It was also confirmed that during this recreational program Employee E5, Activities Director, had stepped away from the area/table where Resident 224 was seated and drinking the hot coffee. Continued interview with Employee E5 revealed that Resident R224 did not receive set-up help from facility staff with the hot coffee. During the interview Employee E5, the Director of Activities, further confirmed that supervision of the residents was not provided as Employee E5 had stepped away from the table. Continued review of facility documentation indicated that nursing staff had been notified that Resident R224 had [MEDICAL CONDITION] a coffee spill on (MONTH) 12, (YEAR), at approximately 11:45 a.m. - 11:55 a.m. Facility documentation reflected that nursing staff had assessed Resident R224's right thigh burn and noted a 1 cm. (centimeter) by 0.5 cm area with the skin removed. Facility documentation further indicated that Resident R224 had reported to the registered nurse, that it hurt so bad and rated the pain as an eight (pain rating scale of 0-10; with 0=equals no pain and 10 equals extreme pain). Review of the (MONTH) (YEAR), Medication Administration Record [REDACTED]. Continued review of facility documentation revealed that nursing staff had not contacted a staff physican regarding Resident R224's burn until 1:30 p.m. approximately one and half hours after the burn had occurred. Facility documentation indicated that the resident was subsequently transferred to the emergency room for further evaluation and treatment at approximately 3:00 p.m. four hours after the burn had occurred. Review of the facility documentation indicated that the emergency physician examined the resident and determined that the resident had sustained second [MEDICAL CONDITION](partial thickness burn which affects both the upper and lower layers of skin) to the right and left medial (inner) thighs, consistent with a scald wound from hot liquid. The resident was further noted with blistering to the left thigh and a first degree burn (injury to the outer layer of skin caused by heat) to the lower abdomen, following the hot coffee spill. Further review of emergency room physician documentation indicated that the resident should have follow up at a burn clinic. Interview with Employee E1, Administrator, on (MONTH) 30, (YEAR), a 1:00 p.m. confirmed that there was a delay in physician notification related to Resident R224's coffee spill and subsequent burns. Facility staff failed to immediately notify the physician of a hot coffee spill for one of 18 residents reviewed (Resident R224) which resulted actual harm to the resident who sustained first and second [MEDICAL CONDITION] both thighs and a first degree burn to the abdomen. 28 Pa. Code 201.14(a) Responsibility of license Previously cited 06/02/17, 05/05/16 28 Pa. Code 201.18(a) Management Previously cited 06/02/17 28 Pa. Code 201.18(b)(1) Management Previously cited 06/02/17, 05/05/16 28 Pa. Code 201.18(b)(3) Management Previously cited 06/02/17 28 Pa. Code 201.18(e)(1) Management Previously cited 05/05/16 28 Pa. Code 211.5(f) Clinical records Previously cited 06/02/17, 05/05/16 28 Pa. Code 211.15(g)(h) Clinical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Previously cited 06/02/17, 05/05/16