Embassy Of Hearthside

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

will be evaluated to determine if they are considered significant or not. If a medication error occurs, the nurse assesses and examines the resident's condition and notifies the physician as soon as possible. The nurse will monitor and document the resident's condition, including response to medical treatment or nursing interventions. Once the resident is stable, the nurse reports the incident to the appropriate supervisor and completes the incident report. Closed clinical record review revealed the facility admitted Resident CR1 on June 3, 2025. Further review revealed Resident CR1 remained in the facility until July 21, 2025, when he was sent to the hospital and was admitted with diagnoses including anemia (lack of healthy red blood cells), bronchitis, and hyperglycemia (high blood sugar). Review of Resident CR1's Medication Administration Record (MAR, a form utilized by the facility to document the administration of medications) dated July 2025, revealed the following three orders for Prednisone (medication used to decrease inflammation and suppress the immune system): Prednisone 20 milligrams (mg), two tablets one time only for cough and congestion on July 21, 2025, at 1:15 AMPrednisone 20 mg, two tablets four times a day for cough and congestion for four days on July 21, 2025, at 8:00 AMPrednisone 20 mg, two tablets one time a day for cough and congestion for four days on July 22, 2025, at 8:00 AM Interview with the Director of Nursing on August 25, 2025, at 1:20 PM confirmed the registered nurse wrote the Prednisone order on July 21, 2025, at 8:00 AM wrong, indicating it was supposed to be Prednisone 20 mg, two tablets one time a day instead of four times a day. The licensed practical nurse administered Resident CR1's 8:00 AM and 1:00 PM Prednisone doses. The nurse did not report the medication error, or complete an incident report,

The facility failed to provide the highest practical care to Resident CR1 28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Hearthside

450 Waupelani Drive State College, PA 16801

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation and staff interview, it was determined the facility failed to store food in accordance with professional standards for food service in the facility's main kitchen. Findings include: An observation in

the facility's main kitchen on August 25, 2025, at 11:30 AM with Employee 1 (dietary manager) revealed the following: In the dry storage area, there was a bag of elbow macaroni, and a bag of opened egg noodles, with no open or use by dates. On the bread racks, there were six packs of English muffins, three loaves of bread, two packs of sandwich rolls, and one pack of hotdog rolls with no received or use by dates. In the walk-in Freezer, there was a box of mixed vegetables with no open or use by dates. The vegetables were not covered or sealed. In the walk-in refrigerator, there were boxes of mushrooms, lemons, and oranges with no open or use by dates. The items were not covered or sealed. In the reach-in cooler, there was an opened container of grape jelly and strawberry juice with no open or use by dates. In the production area, there was an opened box of thick and easy, bag of flour, container of peanut butter, container of quick oats, box of cream of rice, box of potato pearls, and a container identified by Employee 1 as Cream of Wheat. All of these items were opened with no open date or use by dates. The above findings in the main kitchen were reviewed with the Nursing Home Administrator and Director of Nursing on August 25, 2025, at 3:04 PM. 483.60(i)(2) Store, prepare, food safe and sanitaryPreviously cited 3/14/25 28 Pa. Code 201.14 (a) Responsibility of Licensee

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