Health inspection·November 22, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on clinical record review, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for one of one resident reviewed (Resident 1). Residents Affected - Few Findings include: Clinical record review revealed the facility admitted Resident 1 on June 12, 2024. Nursing documentation dated on November 12, 2024, at 12:27 PM revealed the licensed practical nurse noted after Resident 1 began eating his meal tray, he began to have a mild coughing episode and indicated he was not feeling well. The licensed practical nurse documented the registered nurse was aware. Nursing documentation dated November 12, 2024, at 1:13 PM indicated that the licensed practical nurse documented Resident 1's oxygen saturation was at 75% on room air and the registered nurse was aware. Nursing documentation dated November 12, 2024, at 4:35 PM indicated the licensed practical nurse noted while Resident 1 was eating dinner he began coughing and spitting up large amounts of mucus with particles of food. The licensed practical nurse noted the registered nurse was aware. Nursing documentation dated November 12, 2024, at 5:00 PM revealed that the licensed practical nurse noted Resident 1 was unresponsive, sternal rub was done with no success, and color was very gray. The registered nurse was called to the unit immediately. Resident 1 remained unresponsive, with large amounts of mucus and food running out of his mouth. Nursing documentation noted Resident 1 ceased to breath at 6:06 PM. Review of the current facility policy entitled Change in Condition Notification Protocol, revealed as soon as the nurse has been made aware of a change in condition by an employee, and once the nurse has been able to assess the resident, the nurse will initiate a Change in Condition Tool (SBAR). The nurse will gather pertinent information as directed by the SBAR prior to making a phone call to the physician. The facility will inform the resident, consult the resident's physician, and notify the resident's representative. They will complete notification to the resident's physician and/or nurse practitioner, or physician's assistant to discuss the resident status and the care for the resident. Further review of Resident 1's clinical record revealed the nurse did not complete the Change in Condition Tool. There was no documentation in Resident 1's closed clinical record that the nurse notified Resident 1's physician; however, the CRNP (certified registered nurse practitioner) sent an (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395868 Printed: 05/15/2026 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 395868 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2024 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)