EMBASSY OF HILLSDALE PARK
For profit - Corporation
74 Beds
EMBASSY HEALTHCARE
Data: November 2025
Trust Grade
35/100
#414 of 653 in PA
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Embassy of Hillsdale Park has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #414 out of 653 facilities in Pennsylvania places it in the bottom half, and it is the lowest-ranked option in Indiana County at #5 of 5. The facility's trend is stable, with 12 issues found in both 2024 and 2025, but these are concerning due to their nature. Staffing is relatively strong with a 4/5 star rating and a turnover rate of 40%, which is better than the state average, suggesting that staff are experienced. However, recent inspections revealed serious issues, such as a failure to protect a resident from abuse and not following physician orders for blood sugar checks, which raise alarm about the quality of care. On a positive note, the facility has not incurred any fines, indicating no recent compliance issues.
- Trust Score
- F
- In Pennsylvania
- #414/653
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ○ Average
- 40% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ○ Average
- Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 37%
Review needed
12 → 12 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 12 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below Pennsylvania average of 48%
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 40%
Near Pennsylvania avg (46%)
Typical for the industry
Chain: EMBASSY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 34 deficiencies on record
Mar 2025
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide a reasonable accommodation of needs by failing t...
Read full inspector narrative →
Based on a review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide a reasonable accommodation of needs by failing to ensure that the call bell was within reach for one of 33 residents reviewed (Resident 27).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated December 13, 2024, indicated that the resident was cognitively impaired and required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had recent falls, and staff were to ensure the call bell was within reach.
The facility's call bell policy, dated November 8, 2024, indicated that the call bell would be within easy reach and secured if needed.
Observations of Resident 27 on March 3, 2025, at 10:38 a.m. revealed that the resident was sitting in his wheelchair in the middle of his room with his call bell lying on his bed out of the resident's reach. Interview with Resident 27 at that time revealed that he does not get help when needed because his call bell has been out of reach.
Interview with Nurse Aide 1 at that time revealed that Resident 27 was capable of using his call bell and it should have been placed within her reach.
Interview with the Nursing Home Administrator on March 4, 2025, at 10:25 a.m. confirmed that the call bell should have been within Resident 27's reach.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, clinical record reviews, and staff interviews, it was determined that the facility faile...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that a resident's baseline care plan included information regarding the resident's immediate care needs for one of 33 residents reviewed (Resident 74).
Findings include:
A facility policy for baseline care plans, dated November 8, 2024, indicated that the facility will develop a baseline care plan within 48 hours of a resident's admission that includes the minimum healthcare information necessary to properly care for a resident including, but not limited to, initial goals based on admission orders and physician's orders. Interventions shall be initiated that address the resident's current needs including any special needs such as for intravenous therapy (administration of fluids and/or medications directly into a person's vein).
A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m., revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs). She had a peripherally inserted central catheter (PICC - a thin tube inserted into a vein and used long term for the administration of fluids and/or medications) in her right upper arm for maintenance at that time.
Physician's orders for Resident 74, dated February 25, 2025, included orders for the staff to maintain the resident's PICC and flush each port every 12 hours with 5 milliliters (ml) of normal saline followed by 5 ml of Heparin (an anticoagulant medication used to keep intravenous catheters open and flowing freely); for the registered nurse to change the PICC dressing, extension set, and cap every seven days on the day shift and as needed for leakage, blockage and/or soilage; and for staff to measure the external catheter length from insertion site to the end of the injection cap in centimeters (cm) on admission, with each dressing change every seven days on the day shift and as needed.
Review of Resident 74's clinical record revealed no documented evidence that a baseline care plan was developed to address the resident's PICC and related PICC care.
Interview with the Nursing Home Administrator on March 5, 2025, at 12:17 p.m. confirmed that there was no documented evidence that a baseline care plan was developed to address Resident 74's PICC and related PICC care.
28 Pa. Code 211.12(d)(1) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized ...
Read full inspector narrative →
Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 33 residents reviewed (Resident 29).
Findings include:
The facility's policy for Comprehensive Care Plans, dated November 8, 2024, indicated that the facility develops and implements a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated February 4, 2025, revealed that the resident was cognitively impaired, required assistance with care needs, was receiving hospice services, and had a diagnosis of Alzheimer's disease.
Physician's orders for Resident 29, dated February 6, 2025, revealed that the resident was admitted to 365 Hospice on February 4, 2025.
Review of Resident 29's clinical record revealed that there was no documented evidence that a care plan was developed to address the resident's need for hospice services.
An interview with the Nursing Home Administrator on March 5, 2025, at 9:31 a.m. confirmed that there was no documented evidence that a care plan was developed to address Resident 29's need for hospice services.
28 Pa. Code 201.24(e)(4) admission Policy.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect ...
Read full inspector narrative →
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 33 residents reviewed (Residents 9, 31).
Findings include:
The facility's policy for Comprehensive Care Plans, dated November 8, 2024, indicated that the facility develops and implements a comprehensive, person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated January 18, 2025, revealed that the resident was cognitively impaired, was rarely understood, and could rarely understand others. A care plan, dated October 13, 2021, revealed that hospice was to be notified if the resident goes into cardiac arrest.
Physician's orders for Resident 9, dated July 19, 2024, revealed that the resident was discharged from hospice care.
Interview with the Nursing Home Administrator on March 5, 2025, at 9:31 a.m. confirmed that the resident was no longer on hospice and her care plan should have been updated to reflect that.
A quarterly MDS assessment for Resident 31, dated January 16, 2025, revealed that the resident was cognitively intact, required assistance with care needs, had no pressure ulcers or wounds, and had diagnoses that included diabetes, peripheral vascular disease (a disease causing poor blood circulation to lower limbs), and acquired absence of the left leg below the knee. A skin integrity care plan for Resident 31, dated May 9, 2019, included an intervention for a stump shrinker to be worn to shape the amputation site for a possible prosthesis (an artificial body part) and an intervention for contact precautions (used to prevent the spread of infection passed through direct contact with an infected person or their environment) related to Methicillin-resistant Staphylococcus aureus (MRSA) infection (type of staph bacteria resistant to many antibiotics making treatment difficult).
Review of Resident 31's clinical record revealed no documented evidence that the resident continued to wear a stump shrinker and no documented evidence that the resident had a MRSA infection requiring contact precautions.
Interview with the Nursing Home Administrator on March 6, 2025, at 9:55 a.m. confirmed that Resident 31's care plan should have been revised to reflect that the stump shrinker was no longer used and that the resident was no longer on contact precautions for MRSA.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding wound treatments were followed for one of 33 residents reviewed (Resident 74).
Findings include:
A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m. revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs).
Physician's orders for Resident 74, dated March 1, 2025, included orders to cleanse the resident's right lateral diabetic foot ulcer with normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), apply betadine (a solution used to treat and prevent infection) to the base of the wound, and secure with abdominal dressing (used for a wound with large amounts of drainage or used as padding for pressure points and cushioning) and rolled gauze (used to hold the dressing in place) daily and as needed.
Observations of Resident 74's wound care on March 5, 2025, at 10:08 a.m. revealed that Licensed Practical Nurse 2, with gloved hands, cleansed the resident's right lateral foot with normal saline, removed her gloves, washed her hands, applied new gloves, applied betadine to the wound, and left the wound open to air.
Interview with Licensed Practical Nurse 2 on March 5, 2025, at 11:52 a.m. revealed that she was not aware that the wound to Resident 74's right lateral foot was to be covered with an abdominal dressing and wrapped with rolled gauze.
Interview with the Nursing Home Administrator on March 5, 2025, at 12:22 p.m. confirmed that the order for Resident 74's wound to her right lateral foot included an order to cover the wound with abdominal dressing and wrap with rolled gauze. She confirmed that the wound should have been covered and wrapped.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide proper positioning in a wheelchair for one of 33 residents reviewed (Residen...
Read full inspector narrative →
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide proper positioning in a wheelchair for one of 33 residents reviewed (Resident 38).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated November 29, 2024, revealed that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included Alzheimer's dementia and depression. Physician's orders for the resident, dated September 17, 2024, included orders for the resident to be seated in a Broda chair (modified wheelchair) at all times when out of bed with bolsters bilaterally to trunk, skil-care back pillow, and leg rests on during transport and off after transport.
Observations on March 3, 2025, at 10:19 a.m. revealed that Resident 38 was sitting in a Broda chair in the activity room, and she was leaning to the right side with her head lying on the armrest.
Observations on March 6, 2025, at 10:40 a.m. revealed that Resident 38 was in a Broda chair in the activity room, and she was leaning to the right side with her head lying on the armrest.
Interview with the Director of Rehabilitation on March 6, 2025, at 10:40 a.m. confirmed that the bilateral bolsters were not in place on Resident 38's Broda chair per physician orders.
Interview with the Nursing Home Administrator on March 6, 2025, at 11:19 a.m. confirmed that Resident 38 did not have the bilateral bolsters to prevent the resident from leaning.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the environment remained as free of accident hazards a...
Read full inspector narrative →
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the environment remained as free of accident hazards as possible for one of 33 residents reviewed (Resident 14).
Findings include:
A facility policy for resident alarms, dated November 8, 2024, indicated that the use of alarms does not eliminate the need for adequate supervision of the resident. Wander/elopement alarms alert staff when the resident nears or exits an area or building. When alarms are utilized, additional monitoring shall be provided, including but not limited to verifying alarms are used in accordance with the resident's care plan and verifying alarms are working properly.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated November 10, 2024, indicated that the resident was cognitively impaired, required assistance with care needs, and had diagnoses that included Alzheimer's dementia. A care plan for the resident, dated March 11, 2024, revealed that the resident was a high risk for elopement due to recent exit-seeking behaviors and wandering. Interventions included a wanderguard to reduce the risk of elopement and to check the device for proper functioning per facility protocol.
Physician's orders for Resident 14, dated December 4, 2024, included an order for the resident to have a wanderguard in place for safety.
A nursing note for Resident 14, dated February 8, 2025, at 9:21 p.m. revealed that the resident had an episode of increased confusion during the first half of the shift and stated she was going home, packing her belongings, and wandering through the hallways.
There was no documented evidence in Resident 14's clinical record to indicate that the wanderguard was checked for proper functioning per the facility policy and the resident's plan of care.
Interview with the Nursing Home Administrator on March 6, 2025, at 11:59 a.m. confirmed that there was no documented evidence that Resident 14's wanderguard was monitored to verify that it was working properly and it should have been.
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)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to flush a PICC line (a tube placed in a vein that can be used to deliver fluids and/or medications) as ordered by the physician for one of 33 residents reviewed (Resident 74).
Findings include:
A nursing note for Resident 74, dated February 25, 2025, at 4:23 p.m. revealed that the resident was admitted to the facility on [DATE], with diagnoses that included a diabetic foot ulcer (a wound to the foot due to a complication of diabetes) and peripheral vascular disease (a disease causing poor blood circulation to lower limbs). She had a peripherally inserted central catheter (PICC - a thin tube inserted into a vein and used long term for the administration of fluids and/or medications) in her right upper arm for maintenance at that time.
Physician's orders for Resident 74, dated February 25, 2025, included orders for the staff to maintain the resident's PICC and flush each port every 12 hours with 5 milliliters (ml) of normal saline followed by 5 ml of Heparin (an anticoagulant medication used to keep intravenous catheters open and flowing freely).
Observations of Resident 74's PICC dressing change on March 5, 2025, at 9:50 a.m. revealed that after the PICC dressing was applied, Registered Nurse 3 flushed the resident's PICC with one syringe containing 5 ml of normal saline.
Interview with Registered Nurse 3 on March 5, 2025, at 12:13 p.m. confirmed that she flushed Resident 74's PICC with normal saline and did not flush the PICC with the 5 ml of heparin per the physician's orders. She indicated that she was not aware that the PICC was to be flushed with heparin as well.
Interview with the Nursing Home Administrator on March 5, 2025, at 12:17 p.m. confirmed that Registered Nurse 3 should have flushed Resident 74's PICC with the 5 ml of heparin per the physicians orders and she did not.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medi...
Read full inspector narrative →
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 33 residents reviewed (Resident 46).
Findings include:
The facility's policy regarding medication administration, dated November 8, 2024, indicated that staff were to document that medication was given on the appropriate line of the resident's Medication Administration Record (MAR).
Physician's orders for Resident 46, dated November 20, 2023, included an order for the resident to receive a 1 milligram (mg) tablet of Ativan (an anti-anxiety medication) every six hours as needed.
Resident 46's controlled drug records for January and February 2025 revealed that a 1 mg dose of Ativan was signed-out on January 21, 2025, at 7:50 a.m. and February 28 2025, at 8:00 a.m.; however, the resident's clinical record, including the MAR, contained no documented evidence that the Ativan was actually administered to the resident.
Interview with the Director of Nursing on March 16, 2025, at 12:44 p.m. confirmed that there was no documented evidence that the doses of Ativan that were signed-out by the nurse on the above dates were actually administered to Resident 46.
28 Pa. Code 211.9(h) Pharmacy Services.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to t...
Read full inspector narrative →
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of as needed anti-anxiety medications for one of 33 residents reviewed (Resident 46).
Findings include:
A quarterly Minimum Date Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated February 1, 2025, indicated that the resident was cognitively impaired, was understood and was able to be understood by others, and had physical behaviors directed toward others. The resident's care plan dated January 14, 2024, revealed that staff were to minimize the potential for disruptive behaviors by offering tasks that divert attention. Physician's orders, dated February 4, 2025, and February 19, 2025, included an order for the resident to receive 1 milligram (mg) of Ativan (an anti-anxiety medication) every six hours as needed for agitation.
Resident 46's Medication Administration Record (MAR) for February 2025 and March 2025 revealed that staff administered as needed Ativan for agitation on February 1, 2025, at 4:05 a.m.; February 3, 2025, at 7:46 a.m.; February 6, 2025, at 11:23 p.m.; February 7, 2025, at 3:23 a.m. and 6:02 a.m.; February 9, 2025, at 5:47 p.m.; February 14, 2025, at 6:09 a.m. and 12:16 p.m.; February 15, 2025, at 7:46 a.m. and 3:00 p.m.; February 16, 2025, at 7:55 a.m. and 3:00 p.m.; February 19, 2025, at 4:00 p.m.; February 20, 2025, at 6:53 a.m. and 2:30 p.m.; February 21, 2025, at 6:33 a.m. and 6:23 p.m.; February 22, 2025, at 4:00 p.m.; February 23 2025, at 6:10 p.m.; February 24, 2025, at 6:14 a.m.; February 25, 2025, at 6:20 a.m.; February 26, 2025, at 5:00 p.m.; February 28, 2025, at 4:00 p.m.; March 1, 2025, at 7:37 a.m. and 5:30 p.m.; March 2, 2025, at 7:10 a.m. and 3:56 p.m.; and March 4, 2025, at 7:21 a.m.
There was no documented evidence in Resident 46's clinical record to indicate that non-pharmalogical interventions were attempted prior to the Ativan being administered on the above dates and times.
Interview with the Nursing Home Administrator on March 5, 2025, at 9:05 a.m. confirmed that there was no documented evidence to indicate that non-pharmacological interventions were attempted prior to the administration of Ativan for Resident 46.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ...
Read full inspector narrative →
Based on review of the facility's plans of correction 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 plans of corrections for State Survey and Certification (Department of Health) survey ending April 11, 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 March 6, 2025, identified repeated deficiencies related to abuse and neglect, updating/revising care plans, quality of care, and a safe environment that is free of accident hazards.
The facility's plan of correction for a deficiency regarding failure to ensure residents were free from abuse and neglect, cited during the survey ending April 11, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F600, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding abuse and neglect.
The facility's plan of correction for a deficiency regarding a failure to update/revise residents' care plans, cited during the survey ending April 11, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating/revising residents' care plans.
The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending April 11, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.
The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending April 11, 2024, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards.
Refer to F600, F657, F684, F689.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abu...
Read full inspector narrative →
Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 33 residents reviewed (Resident 54).
Findings include:
The facility's policy for abuse, dated November 8, 2024, indicated that the facility will not tolerate abuse, neglect, and exploitation of its residents or the misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated February 11, 2025, revealed that the resident was rarely understood, could rarely understand, and had diagnoses that included Alzheimer's disease and Down's syndrome. A care plan for Resident 54, dated January 29, 2024, revealed that the resident was at high risk for elopement and had impaired cognitive function. Interventions for Resident 54 indicated that if she was wandering in a potentially unsafe area or situation redirect to safer area and offer diversional activities.
A quarterly MDS assessment for Resident 56, dated November 11, 2024, revealed that the resident was understood and could understand others, and had diagnoses that included dementia. A care plan for Resident 56, dated April 15, 2024, revealed that she exhibited behaviors that included physically abusive attacks on staff and/or other residents, scratching, refusal of care and meals, and yelling and screaming. Interventions for Resident 56 included redirecting residents who were attempting to enter her room because this upsets her.
A nursing note for Resident 54, dated August 11, 2024, at 7:23 p.m. revealed that the nurse aide brought Resident 54 to the nurse after the nurse aide witnessed Resident 56 grabbing her by her arm and screaming at her to get out of her room. The licensed practical nurse looked at Resident 54's left inner arm, and there were three fingernail prints on her arm.
The facility report, dated August 11, 2024, at 6:50 p.m. indicated that Resident 54 was attempting to get into Resident 56's room. Resident 56 then grabbed Resident 54's arm causing three scratch marks. The nurse aide removed Resident 54 from the room.
A nursing note for Resident 54, dated August 23, 2024, at 1:32 p.m. revealed that the nurse was notified that the resident was witnessed lying in Resident 56's bed. Resident 56 was observed hitting Resident 54 on her waist. No injuries were noted, and staff removed Resident 56 from her room.
A nurse aide witness statement, dated August 23, 2024, revealed that she walked into the room after she heard Resident 54 yelling for help. She observed Resident 56 and another resident standing over top of Resident 54 slapping her and yelling, Get out! The residents were separated, and the registered nurse was notified.
There was no documented evidence in Residents 54's clinical record to indicate that she was being monitored for wandering.
A nursing note for Resident 54, dated September 5, 2024, at 3:43 p.m., revealed that the nurse aide brought Resident 54 to the nurse after the nurse aide witnessed Resident 56 grabbing her by her arm and screaming at her to get out of her room. The licensed practical nurse looked at Resident 54's left inner arm, and there were three fingernail prints on her arm.
A nursing note for Resident 54, dated September 5, 2024, at 7:55 p.m., revealed that Resident 54's left arm remained slightly pink where fingernail marks occurred from the altercation earlier. The resident was observed staying in her room for a long time after the incident and if you stated her name, she would jump and become very fidgety.
There was no documented evidence in Residents 54's clinical record to indicate that she was being monitored for wandering.
Interview with the Nursing Home Administrator on March 6, 2025, at 9:56 a.m. confirmed that Resident 56 had multiple abusive interactions with Resident 54 and that there was no documented evidence that staff was monitoring Resident 54 when wandering.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.29(j) Resident Rights.
Apr 2024
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abu...
Read full inspector narrative →
Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 33 residents reviewed (Resident 58).
Findings include:
The facility's policy for abuse, dated March 14, 2024, indicated that the facility will not tolerate abuse, neglect, and exploitation of its residents or the misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 117, dated June 8, 2023, revealed that the resident was usually understood, could usually understand, and had diagnoses that included dementia and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A care plan for Resident 117, dated September 21, 2023, revealed that he exhibited behaviors of playing in his food, taking items, wandering (to move around or go to different places usually without having a particular purpose or direction), abusive language, sexually-inappropriate behaviors, and threatening behaviors. Interventions for Resident 117 indicated that if he is wandering in the hallway, attempt to keep him away from other residents, keep him out of reach of other residents when feasible, and when in the dining room for meals and activities attempt to keep the resident out of reach of other resident to prevent future incidents.
A significant change in status MDS assessment for Resident 58, dated August 29, 2023, revealed that the resident was understood, could understand, and had a diagnosis of Alzheimer's disease.
A nursing note for Resident 58, dated September 8, 2023, at 12:50 p.m. revealed that the nurse was called from the dining room by the care aides related to a resident-to-resident altercation. Resident 58 was in her room when Resident 117 was trying to enter. Resident 58 was then observed being kicked by Resident 117. The resident was then found on the floor in her bedroom. Resident 58 stated that Resident 117 was trying to enter her room and she told him that she did not want him in there. Resident 117 then kicked her causing her to fall over. The Registered Nurse Supervisor was called and notified of the incident. The resident's injuries were assessed by supervisor. The resident was assisted by staff back into her recliner at this time.
A nursing note for Resident 58, dated September 8, 2023, revealed that the licensed practical nurse on the floor notified the registered nurse that another resident kicked the resident and she fell to the floor. The nurse aide witnessed the other resident kicking this resident. When the registered nurse arrived on the floor the resident had gotten up and was in her room sitting in her chair. She stated that, he kicked her, and she fell. She denied having any contact with the resident prior to the incident. The resident stated that her right palm hurts. Upon assessment a bruise was noted on her right palm, which measured 3.5 centimeter (cm) by 1.8 cm. There were two bruises noted to her right elbow measuring 0.5 cm by 0.7 cm and 0.7 cm by 0.3 cm. A small abrasion was noted to her left elbow measuring 0.2 cm by 0.3 cm. A small bruise was noted to her right wrist area measuring 0.5 cm by 0.5 cm. The resident had an unmeasurable abrasion to her right buttock. The physician and psychologist were notified.
The facility report, dated September 8, 2023, indicated that an event occurred on September 8, 2023, at approximately 1:00 p.m. when Resident 117 was attempting to get into Resident 58's room. Resident 117 then kicked Resident 58 causing her to fall. Resident 58 was then assessed by the registered nurse and found to have a bruise on her right palm measuring 3.5 cm by 1.8 cm., two bruises on her right elbow measuring 0.5 cm by 0.7 cm and 0.7 cm by 0.3 cm, a small abrasion on her left elbow measuring 0.2 cm by 0.3 cm, a small bruise on her right wrist area measuring 0.5 cm by 0.5 cm, and an unmeasurable abrasion on her right buttock.
A statement completed by Nurse Aide 1, dated September 8, 2023, revealed that she was walking down the hall and saw Resident 117 halfway into Resident 58's room and then saw Resident 117 kick at Resident 58. Nurse Aide 1 ran into her room, and she was on the floor. Nurse Aide 1 then asked the residents what happened. Resident 58 said Resident 117 kicked her, and Resident 117 admitted kicking her.
Interview with the Nursing Home Administrator on April 10, 2024, at 10:24 a.m. confirmed that Resident 117 kicked Resident 58.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 201.29(j) Resident Rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to review and revise care plans for three of 33 residents ...
Read full inspector narrative →
Based on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to review and revise care plans for three of 33 residents reviewed (Residents 1, 3, 51).
Findings include:
The facility's policy regarding care plans, dated March 14, 2024, indicated that the care plan revisions would be reviewed, and revised as necessary, when a resident experiences a status change.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 19, 2024, indicated that the resident was moderately cognitively impaired and was not receiving an anticoagulant (blood thinner) medication. Resident 1's care plan, dated February 2, 2024, indicated that the resident had the potential for bleeding or hemorrhage related to the use of anti-coagulant medication.
A review of Resident 1's physician's orders and Medication Administration Record (MAR) for April 2024 revealed that the resident was not receiving an anticoagulant medication.
Resident 1's current care plan was not updated to indicate that the resident was not receiving an anti-coagulant medication.
Interview with the Nursing Home Administrator on April 10, 2024, at 1:28 p.m. confirmed that Resident 1's care plan was not updated to include the discontinuation of the anticoagulant medication.
An admission MDS assessment for Resident 3, dated March 29, 2024, indicated that the resident was cognitively intact, required assistance from staff for his daily care needs, and had diagnoses that included a wound infection of a Stage 3 pressure ulcer (a wound developed from constant pressure extend through the skin into deeper tissue and fat but does not reach muscle, tendon, or bone). A care plan for Resident 3, dated April 10, 2024, revealed that the resident was receiving Cefdinir and Ampicillin for a wound infection.
A review of Resident 3's physician's orders and MAR for March and April 2024 revealed that the resident received 300 mg of Cefdinir Oral Capsule daily and 500 mg of Ampicillin oral capsule every six hours from March 23, 2024, to March 30, 2024.
Resident 3's current care plan was not updated to indicate that the resident was no longer receiving the Cefdinir and Ampicillin.
Interview with the Nursing Home Administrator on April 10, 2024, at 9:57 a.m. confirmed that the care plan was not updated to indicate that Resident 3 was no longer receiving Cefdinir and Ampicillin and should have been.
An annual MDS assessment for Resident 51, dated February 1, 2024, revealed that the resident was cognitively intact, required assistance with care needs, and had diagnoses that included atrial fibrillation. A care plan for Resident 51, dated April 23, 2021, indicated that the resident had the potential for bleeding or hemorrhage related to the use of anti-coagulant medication.
Review of Resident 51's current physician's orders revealed that the resident was not receiving an anti-coagulant medication.
Interview with Regional Registered Nurse 2 on April 9, 2024, at 12:01 p.m. confirmed that Resident 51's care plan should have been revised when her anti-coagulant was discontinued in August 2023 and it was not.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infectio...
Read full inspector narrative →
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 33 residents reviewed (Resident 1) who had an indwelling urinary catheter.
Findings include:
The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated March 14, 2024, revealed that care would be taken to follow infection control guidelines when providing catheter care and emptying the drainage bag.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 19, 2024, revealed that the resident was moderately cognitively impaired, required assistance from staff for daily care activities, had an indwelling urinary catheter, and had diagnoses that included neurogenic bladder (lack of bladder control).
Physician's orders, dated December 28, 2023, included an order for the resident to have a urinary catheter, 18 French (size) with a 10 cubic centimeters (cc) balloon (located on the bladder end of the catheter and filled with sterile water to hold the tube in place).
Observations of Resident 1 on April 8, at 12:40 p.m. and April 10, 2024, at 8:18 a.m. revealed that the resident was in a wheelchair in his room and in the hallway, and his catheter tubing was in contact with the floor.
Interview with Registered Nurse 4 on April 10, 2024, at 8:21 a.m. confirmed that Resident 1's catheter tubing was on the floor and should not have been.
Interview with the Nursing Home Administrator on April 10, 2024, at 12:51 p.m. confirmed that Resident 1's catheter tubing should not have been in contact with the floor.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one...
Read full inspector narrative →
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 33 residents reviewed (Resident 22).
Findings include:
The facility's policy regarding medication administration, dated March 14, 2024, indicated that the facility was to administer medication in accordance with the physician orders.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated March 14, 2024, revealed that the resident had diagnoses that included diabetes (a disease that interferes with blood sugar control) and received insulin.
Physician's orders for Resident 22, dated December 15, 2022, included an order for the resident to receive 6 units of Lispro insulin subcutaneously (injected just under the skin) one time a day in the morning, 6 units one time a day at the lunch meal, and 6 units one time a day at the supper meal, and to hold the insulin if the resident's blood sugar was less than or equal to 100 mg/dL.
Resident 22's Medication Administration Records for March and April 2024 revealed that on March 4, 2024, at 7:00 a.m. the resident's blood sugar was 93 mg/dL; on March 6, 2024, at 11:45 a.m. the resident's blood sugar was 98 mg/dL; on March 19, 2024, at 7:15 a.m. the resident's blood sugar was 88 mg/dL; on March 18, 2024, at 7:15 a.m. the resident's blood sugar was 80 mg/dL; and on April 1, 2024, at 11:45 a.m. the resident's blood sugar was 81 mg/dL.
There was no documented evidence that the resident's insulin was held on the above dates as ordered by the physician.
Interview with Regional Registered Nurse 2 on April 9, 2024, at 11:55 a.m. confirmed that Resident 22's insulin was not held when the resident's blood sugar was less than 100 mg/dL on the dates mentioned above and should have been held.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laborat...
Read full inspector narrative →
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a specimen for a laboratory test for one of 33 residents reviewed (Resident 24).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated January 10, 2024, revealed that the resident was understood and understands. Physician's orders, dated January 4, 2024, included an order to obtain a urine culture (a test that looks for and identifies bacteria in urine) and sensitivity (a test that helps find out which antibiotic will be most effective in treating a bacterial infection).
A progress note for Resident 24, dated January 5, 2024, revealed that the resident was straight cathed (an invasive procedure in which a plastic tube is inserted into the bladder) for a dark amber urine and the sample was sent to the lab.
There was no documented evidence that staff obtained a physician's order to obtain Resident 24's urine specimen via catheterization.
Interview with the Nursing Home Administrator on April 11, 2024, at 11:30 a.m. confirmed that there was no evidence that a physician's order was obtained for Resident 24 to be catheterized to obtain the urine specimen.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
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...
Read full inspector narrative →
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 correction for the State Survey and Certification (Department of Health) survey ending May 11, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending April 11, 2024, identified repeated deficiencies related to the revision of care plans, failure to ensure that residents remained free of significant medication errors, and medication storage and labeling.
The facility's plan of correction for a deficiency regarding revising care plans, cited during the survey ending May 11, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the QAPI committee was ineffective in correcting deficient practices related to revising care plans.
The facility's plan of correction for a deficiency regarding failure to ensure that residents remained free of significant medication errors, cited during the survey ending May 11, 2023, 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 F760, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding ensuring that residents remained free of significant medication errors.
The facility's plan of correction for a deficiency regarding proper storage and/or labeling of medications, cited during the survey ending May 11, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storing and labeling residents properly.
Refer to F657, F760, F761.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for blood sugar c...
Read full inspector narrative →
Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for blood sugar checks were obtained by a professional (registered) nurse for one of 33 residents reviewed (Resident 24).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.
Physician's orders for Resident 24, dated October 4, 2024, included an order for the resident to receive one 500 milligram (mg) tablet of Metformin (helps to control the amount of glucose (sugar) in your blood) in the morning at 7:00 a.m.
Resident 24's Medication Administration Record (MAR), dated March and April 2024, revealed that staff were obtaining the resident's blood sugar level prior to the administration of the 500 mg tablet of Metformin in the morning at 7:00 a.m. However, there was no documented evidence that an order was obtained from the resident's physician for staff to obtain the resident's blood sugar level prior to the administration of the Metformin.
Interview with the Nursing Home Administrator on April 11, 2024, at 11:30 a.m. confirmed that there was no documented evidence that an order was obtained from Resident 24's physician for staff to obtain the resident's blood sugar level prior to the administration of the Metformin, and that staff should have obtained an order.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on review of facility policies 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 wi...
Read full inspector narrative →
Based on review of facility policies 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 four of 33 residents reviewed (Residents 12, 14, 22, 24).
Findings include:
The facility's policy regarding medication administration, dated March 14, 2024, indicated that staff were to obtain and record vital signs when applicable or per physician's orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.
An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 12, dated February 22, 2024, revealed that the resident was understood and could understand others, was cognitively intact, and required minimal assistance with care.
A nursing note for Resident 12, dated March 16, 2024, revealed that the nurse aide noticed that the resident's left eye was red and swollen. The physician was notified and orders were received for polymyxin/trimethoprim ophthalmic solution (an eye drop used to treat eye infections) to be administered every three hours for seven days.
A review of Resident 12's Medication Administration Record (MAR) for March 2024 revealed that the eye drops were not available for administration for the first five doses. There was no documented evidence that the physician was made aware that the drops were unavailable or that the treatment would need to be extended to ensure the resident would receive the entire seven-day treatment as ordered.
Interview with the Nursing Home Administrator on April 10, 2024, at 10:27 a.m. confirmed that Resident 12 did not complete the entire treatment as ordered and the treatment should have been completed.
A quarterly MDS assessment for Resident 14, dated December 15, 2023, revealed that the resident was understood, could understand, and had diagnoses that included high blood pressure. A care plan for the resident, dated September 8, 2023, revealed that the resident was at risk for coronary artery disease (a condition that affects the heart). Staff were to administer medications for hypertension and document the response to the medication and any side effects. Staff were to monitor the blood pressure and notify the physician of any abnormal readings.
Physician's orders for Resident 14, dated September 2, 2023, included an order for the resident to receive one 2.5 milligram (mg) of Amlodipine (used to treat high blood pressure) one time a day for hypertension. Staff was to hold the medication for a blood pressure less than 90/60 millimeters of mercury (mm Hg) (a normal blood pressure for most adults is defined as a systolic pressure (top number) of less than 120 mm Hg and a diastolic pressure (bottom number) of less than 80 mm Hg).
Resident 14's Medication Administration Record (MAR), dated March and April 2024, revealed that there was no documented evidence that the resident's blood pressure was obtained prior to the administration of the 2.5 mg tablet of Amlodipine to determine if the medication should be withheld.
Interview with the Nursing Home Administrator on April 10, 2024, at 3:05 p.m. confirmed that there was no documented evidence that Resident 14's blood pressure was obtained prior to the administration of the Amlodipine to determine if the medication should be withheld.
A quarterly MDS assessment for Resident 22, dated December 12, 2023, revealed that the resident was understood, could understood others, was cognitively intact, independent for daily care needs, and received insulin (medication that lowers blood sugar levels).
Physician's orders for Resident 22, dated March 17, 2022, included an order for the resident to have her blood sugar checked four times a day and for the physician to be contacted if the blood sugar is less than 60 or greater than 350.
Resident 22's MAR, dated March, 2024 revealed that on March 3 at 9:00 p.m. the resident's blood sugar was 360 mg/dL; on March 10 at 11:45 a.m. it was 358; and on March 17 at 5:15 p.m. it was 376. There was no documented evidence that the physician was notified about the resident's blood sugar being above 350 mg/dL on these dates and times.
Interview with the Nursing Home Administrator on April 9, 2024, at 11:55 a.m. confirmed that there was no documented evidence that the physician was notified about Resident 22's elevated blood sugars as ordered.
A quarterly MDS assessment for Resident 24, dated January 10, 2024, revealed that the resident was understood, could understand, and had a diagnosis that included high blood pressure. A care plan for the resident, dated October 9, 2023, revealed that the resident was at risk for coronary artery disease. Staff were to administer medications for hypertension and document the response to the medication and any side effects. Staff were to monitor the blood pressure and notify the physician of any abnormal readings.
Physician's orders for Resident 24, dated January 16, 2024, included an order for the resident to receive one 0.1 mg tablet of Clonidine (used to treat high blood pressure) two times a day for hypertension at 7:00 a.m. and 7:00 p.m. Staff were to hold the medication for a blood pressure less than 90/60 mm Hg.
Resident 24's MARS, dated March and April 2024, revealed that there was no documented evidence that the resident's blood pressure was obtained prior to the 7:00 p.m. administration of the 0.1 mg tablet of Clonidine to determine if the medication should be withheld.
Interview with the Nursing Home Administrator on April 11, 2024, at 11:30 a.m. confirmed that there was no documented evidence that Resident 24's blood pressure was obtained prior to the administration of the Clonidine to determine if the medication should be withheld.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for two of 33 residents re...
Read full inspector narrative →
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for two of 33 residents reviewed (Residents 3, 30).
Findings include:
The facility's policy regarding pressure ulcers, dated March 14, 2024, indicated that the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.
An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 29, 2024, indicated that she was cognitively intact, had no history of rejecting care, required extensive assistance from staff for daily care needs, and had an unhealed Stage 3 pressure ulcer.
A physician's progress note, dated March 29, 2024, revealed that Resident 3 was to be assessed for an air mattress to assist with pressure distribution.
Observations of Resident 3 on April 8, 2024, at 11:35 a.m. revealed that the resident did not have an air mattress. There was no documented evidence in the clinical record that Resident 3 had been assessed for an air mattress as requested by the physician.
Interview with the Nursing Home Administrator on April 10, 2024, at 9:33 a.m. confirmed that the resident did not have an air mattress, was never assessed for an air mattress, and that he should have been per the physician's request.
A quarterly MDS assessment for Resident 30, dated March 14, 2024, indicated that the resident was cognitively intact and had pressure ulcers (skin breakdown caused by pressure).
A wound clinic note, dated March 22, 2024, revealed that Resident 30 had a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the coccyx (lower part of spine) that measured 5.0 x 4.5 x 5.0 centimeters (cm) with undermining (tissue breakdown beneath the skin), and it was recommended that the wound be cleansed with 0.125 percent Dakins (used to prevent infection) solution and collagen (used to stimulate wound healing) and silver alginate (dressing used to prevent infection) be applied to the coccyx twice a day.
A wound clinic note, dated March 29, 2024, revealed that Resident 30 continued to have a Stage IV pressure ulcer to the coccyx, and it was recommended that the wound be cleansed with 0.125 percent Dakin's solution, and collagen and silver alginate be applied to the coccyx twice a day.
The Treatment Administration Record for Resident 30 for March 2024 revealed that the application of collagen and silver alginate to the resident's coccyx twice a day was not started until March 30, 2024.
There was no documented evidence that the application of collagen and silver alginate to Resident 30's coccyx twice a day was started following the recommendations of the wound clinic on March 22, 2024.
Interview with the Nursing Home Administrator on April 10, 2024, at 9:34 a.m. confirmed that the treatments to Resident 30's coccyx were not completed as recommended by the wound clinic on March 22, 2024.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the residents' environment remained free of accident hazards caused by residents with aggressive behaviors for four of 33 residents reviewed (Residents 44, 58, 61, 63).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated December 15, 2023, revealed that she was understood, could understand, and had a diagnosis of dementia. A care plan for the resident, dated September 8, 2023, revealed that the resident had an alteration in behavior related to abusive attacks on staff and/or other residents; verbally abusive, threatening behaviors; argumentative with staff; yells at staff and other residents, and a history of resident-to-resident altercations. Staff were to intervene as needed to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to another location as needed.
A nursing note for Resident 14, dated December 25, 2023, at 5:30 p.m. revealed that the resident was hollering at the residents in the dining room and singled one resident out, threatening to hit her with her hands clenched in fists. Residents were separated and Resident 14 was in her room at this time. A nursing note at 7:10 p.m. revealed that the resident went into Resident 58's room hollering at the resident. This licensed practical nurse went down the hall to see what was going on. Resident 14 was shaking Resident 58 and hit the resident in the stomach with a closed fist several times. The licensed practical nurse told the resident to stop, and she pushed Resident 58 and made the resident stumble out of her room. The licensed practical nurse told the resident that she cannot hit or push other residents and the resident insisted that this is her house and that Resident 58 was burning it down.
A nursing note for Resident 14, dated January 5, 2024, revealed that during breakfast another resident began speaking inappropriately to this resident, and she in turn, began verbally making comments that she would punch the other resident.
A nursing note for Resident 14, dated March 20, 2024, revealed that the writer was called to the unit at 8:30 p.m. by the licensed practical nurse reporting that the resident had slapped Resident 63's arm while in the hallway. The incident was witnessed by the hospitality aide who had reported it to the licensed practical nurse. The licensed practical nurse immediately separated the two residents. Upon entry to the unit both residents were away from one another and resting in their wheelchairs with staff nearby. Neither resident could give a description of what had occurred.
A significant change in status MDS assessment for Resident 117, dated June 8, 2023, revealed that the resident was usually understood, usually understands, and had diagnoses that included dementia and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). A care plan for the resident, dated September 21, 2023, revealed that the resident had exhibited behaviors of playing in his food, taking items, wandering (to move around or go to different places usually without having a particular purpose or direction), abusive language, sexually-inappropriate behaviors, and threatening behaviors. If the resident was wandering in the hallway, attempt to keep him away from other residents, keep the resident out of reach of other residents when feasible, and when in the dining room for meals and activities attempt to keep the resident out of reach of other resident to prevent future incidents.
A nursing note for Resident 44, dated July 16, 2023, revealed that the nurse aide hollered for the licensed practical nurse to come help her. The nurse aide stated, Resident 117 hit Resident 44 on the back. Resident 44 was standing in room [ROOM NUMBER] behind the nurse aide. The registered nurse was notified after Resident 117 was taken to his room.
A nursing note for Resident 117, dated September 8, 2023, at 1:22 p.m. revealed that the licensed practical nurse on the floor notified the registered nurse that this resident kicked Resident 58 in the leg and caused her to fall to the floor with minor injuries noted. Upon arrival to the unit the resident was in the hallway in his wheelchair. When asked what happened he refused to say anything. The licensed practical nurse stated that he told her he kicked Resident 58 after she kicked him. Resident 58 denied kicking him. The resident continues to self-propel in the hallway currently. A nursing note at 1:28 p.m. revealed that the licensed practical nurse notified the registered nurse that the resident punched Resident 44 in the buttocks as she walked away from him. Upon arrival, the resident was seen sitting in his room. The resident refused to explain what happened.
A statement Social Worker 3, dated September 8, 2023, revealed that he was completing MDS's in his office around 1:00 p.m. to 1:15 p.m. when a nurse aide called him into the hallway to help keep Resident 117 away from Resident 58. He brought Resident 117 to his office and spoke about what happened. Resident 117 said, I was going into her room, she told me to get out, she turned around and I kicked her in the butt. Resident 117 was in the office for about 15 to 20 minutes when the phone rang. Social Worker 3 answered and spoke on the phone and when he hung up, Resident 117 was no longer in his office.
A quarterly MDS assessment for Resident 58, dated February 29, 2024, revealed that the resident was understood, understands, and had a diagnosis of Alzheimer's disease. A care plan for the resident, dated February 23, 2023, revealed that the resident is/has a potential to be physically aggressive.
A nursing note for Resident 58, dated March 19, 2024, revealed that the licensed practical nurse notified the registered nurse at 6:30 p.m. that the resident had hit Resident 61 once in the back and another time in the left breast.
Following the above incidents, there was no documented evidence that the facility analyzed the key times, places, circumstances, and triggers that caused the multiple episodes of resident-to-resident altercations.
Interview with the Nursing Home Administrator on April 10, 2024, at 10:24 a.m. confirmed that Resident 117 had an altercation with Resident 58 and after the altercation then went and had an altercation with Resident 44. She indicated that Social Worker 3 should have gotten someone else to watch Resident 117 when he received the phone call.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, medication manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure that medica...
Read full inspector narrative →
Based on review of policies and clinical records, medication manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled/dated for three of 33 residents reviewed (Residents 10, 11, 45).
Findings include:
The facility's policy for labeling medications, dated March 14, 2024, indicated that all pre-filled pens and multi-dose vials of medication maintained in the facility shall be labeled with date opened and the initials of the healthcare professional, and are to be discarded within 28 days unless otherwise specified by the manufacturer.
The most current manufacturer's instructions for insulin Humalog Kwikpen Pen-injector 100 unit/ml (milliliter) solution (a fast acting insulin) indicated that prefilled pens that are in use should be kept at room temperature and must be used within 28 days or be discarded.
Physician's orders for Resident 10, dated July 9, 2023, included an order for Keppra solution (medication used to treat seizures) 100 mg/mL 5 ml by mouth two times a day.
Physician's orders for Resident 11, dated March 20, 2023, included an order for Humalog KwikPen Pen-injector 100 unit/ml solution subcutaneously (directly under the skin) before meals and at bedtime per sliding scale.
Physician's orders for Resident 45, dated August 28, 2023, included an order for Humalog KwikPen Pen-injector 100 unit/ml solution subcutaneously (directly under the skin) before meals and at bedtime per sliding scale.
Observations on April 11, 2024, at 10:57 a.m. of the medication cart on the 200 unit revealed a multi-dose bottle of Keppra for Resident 10 that was in use and not dated when opened, and a Humalog KwikPen Solution Pen-injector for Resident 11 that was in use and not dated when it was opened.
Interview with Registered Nurse 4 at that time indicated that the multi-dose bottle of Keppra and insulin pen should have been dated when first opened.
Observations on April 9, 2024, at 8:59 a.m. of the medication cart on the ACU unit revealed that there was a Humalog KwikPen Solution Pen-injector for Resident 45 that was in use and it was not dated when it was opened. Interview with Licensed Practical Nurse 5 at that time indicated that the insulin pen should have been dated when first opened.
Interview with the Nursing Home Administrator April 11, 2024, at 10:55 a.m. confirmed that the medications should have been dated when opened.
28 Pa. Code 211.9(a) Pharmacy Services.
Mar 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
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 were provided with showers as scheduled fo...
Read full inspector narrative →
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 were provided with showers as scheduled for one of five residents reviewed (Resident 3).
Findings include:
A facility policy for resident showers dated March 14, 2024, indicated that residents will be provided showers as per request or as per facility schedule protocols.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 21, 2024, indicated that the resident was cognitively impaired, was dependent on staff for showers and bathing, and had diagnoses that included peripheral vascular disease.
A care plan for Resident 3, dated December 12, 2023, indicated that the resident required two staff members to provide care. A care plan, dated January 1, 2024, indicated that the resident was to be assisted with showering as per facility policy weekly.
A review of the facility shower schedule indicated that Resident 3 was to have a shower every Wednesday and Saturday on day shift.
Review of bathing documentation for Resident 3, dated February 20, 2024, through March 19, 2024, indicated that the resident only received two showers during that time. There was no documented evidence that the resident was offered or refused showers weekly as per his care plan.
Observations of Resident 3 on March 20, 2024, at 11:00 a.m. revealed that the resident lying in bed with his eyes closed. Observations on March 20, 2024, at 3:45 p.m. revealed that the resident was lying in bed with several visitors in his room.
Interview with Nurse Aide 3 on March 20, 2024, at 11:05 a.m. revealed that she was the only nurse aide providing care on the North Shore unit and that she was not able to complete her scheduled resident showers. She reported this as a common occurrence and sometimes was unable to get residents out of bed if she could not find help from other staff.
Interview with Licensed Practical Nurse 1 on March 20, 2024, at 11:30 a.m. revealed that only one nurse aide was working on the [NAME] Shore unit; therefore, Resident 3 was not able to be provided his scheduled shower that day.
Interview with Nurse Aide 2 on March 20, 2024, at 11:45 a.m. revealed that she was the only nurse aide providing care on the [NAME] Shore unit and that she was not able to provide the scheduled resident showers on that unit that day.
Interview with the Nursing Home Administrator on March 20, 2024, at 4:00 p.m. confirmed that there was no documented evidence that Resident 3 was offered or refused showers weekly from February 20, 2024, through March 19, 2024, per the resident's care plan.
28 Pa. Code 211.12(d)(5) Nursing Services.
May 2023
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
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 annual Mi...
Read full inspector narrative →
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 annual Minimum Data Set assessments were completed in the required time frame for three of 40 residents reviewed (Residents 45, 64, 65).
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 2019, indicated that an annual MDS assessment was to be completed no later than the assessment reference date (ARD - the last day of the assessment's look-back period) plus 14 calendar days.
A comprehensive MDS assessment for Resident 45, with an ARD of March 10, 2023, was due to be completed on March 23, 2023, but was not signed as completed until April 12, 2023, which was 20 days late.
A comprehensive MDS assessment for Resident 64, with an ARD of November 13, 2022, was due to be completed on November 26, 2022, but was not signed as completed until November 28, 2022, which was two days late.
A comprehensive MDS assessment for Resident 65, with an ARD of March 19, 2023, was completed on April 3, 2023, which was two days late.
Interview with the Nursing Home Administrator on May 11, 2023, at 10:24 a.m. confirmed that the above MDS assessments were not completed in a timely manner.
28 Pa. Code 211.5(f) Clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
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 Quarterly Minimum Data ...
Read full inspector narrative →
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 Quarterly Minimum Data Set assessments were completed within the required timeframe for one of 40 residents reviewed (Resident 1).
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 residents' abilities and care needs), dated October 2019, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days. A quarterly assessment is due every 92 days (ARD of most recent assessment + 92 days).
A quarterly MDS assessment for Resident 1 had an ARD of February 17, 2023. There was no prior MDS completed for Resident 1 in the last 92 days.
Interview with the Nursing Home Administrator on May 11, 2023, at 10:24 a.m. confirmed that the above MDS assessment was not completed in a timely manner.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument and clinical records, as well as staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to th...
Read full inspector narrative →
Based on review of the Resident Assessment Instrument and clinical records, as well as staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments to the required electronic system, the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within 14 days of completion for two of 40 residents reviewed (Residents 64, 65).
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 (federally-mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that comprehensive MDS assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).
A comprehensive MDS assessment for Resident 64 revealed that it was completed on March 6, 2023. The assessment was not submitted to CMS until April 12, 2023. A quarterly MDS assessment for Resident 64 revealed that it was completed on March 6, 2023. The assessment was submitted to CMS on April 19, 2023.
A quarterly MDS assessment for Resident 65 revealed that it was completed on September 27, 2022. The assessment was submitted to CMS on December 21, 2022.
Interview with the Nursing Home Administrator on May 11, 2023, at 10:24 a.m. confirmed that the above MDS assessments were not submitted to CMS in a timely manner.
28 Pa. Code 211.5(f) Clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to add...
Read full inspector narrative →
Based on review of clinical records and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the care needs of residents for one of 40 residents reviewed (Resident 57).
Findings include:
A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated March 8, 2023, revealed that the resident was able to understand others and make herself understood, needed limited assistance for daily care needs, had frequent bladder incontinence, and had diagnoses that included dementia.
A review of Bowel/Bladder Assessments for Resident 57 dated December 8, 2022, and March 7, 2023, revealed that the resident was frequently incontinent of urine.
Observations of Resident 57 on May 8, 2023, at 10:59 a.m. revealed that the resident was being assisted to the bathroom in her room by a nurse aide. The resident's pants were noted to be wet with urine at that time and she required staff to assist her with incontinence care and changing her clothes.
There was no documented evidence that a care plan was developed to address Resident 57's individual care and treatment needs related to her bladder incontinence.
An interview with the Director of Nursing on May 11, 2023, at 12:05 p.m. confirmed that a care plan to address the care needs related to Resident 57's bladder incontinence was not developed and should have been.
28 Pa. Code 211.11(d) Resident care plans.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specifi...
Read full inspector narrative →
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 40 residents reviewed (Resident 59).
Findings include:
A Significant Change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated March 8, 2023, indicated that the resident was cognitively impaired, required extensive assist for daily care needs, and had a diagnosis of dementia.
A nurse's note for Resident 59 dated February 27, 2023, at 8:38 p.m. revealed that the resident had removed his foley catheter (a tube inserted to drain urine), the physician was notified, and new orders were received to discontinue the foley catheter (a flexible tube passed through the urethra and into the bladder to drain urine).
Review of Resident 59's care plan, dated February 28, 2023, included that the resident had the potential for complications related to the use of a foley catheter.
An interview with the Nursing Home Administrator on May 5, 2023, at 3:00 p.m. confirmed that Resident 59 no longer had a foley catheter and that his care plan was not updated to reflect that, and it should have been.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on review of facility policies, manufacturer's instructions, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for on...
Read full inspector narrative →
Based on review of facility policies, manufacturer's instructions, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 40 residents reviewed (Resident 8).
Findings include:
The facility's policy regarding medication administration-insulin administration, dated January 9, 2023, indicated that insulin is a high-risk drug and warrants additional precautions for the safe and effective administration. An important consideration is that many insulin pens require priming or an air-shot prior to administration.
The facility's policy regarding medication administration-injectable medications, dated January 9, 2023, indicated that if a product is dispensed in a pre-filled pen or injection device, check manufacturer's instructions for use. Many pens require priming or air-shots prior to administration.
Manufacturer's instructions for Insulin Glargine, dated August 19, 2022, indicated to double check the insulin concentration and dosage in the syringe or injection device prior to administration. If using a pen or other injector device, prime the device prior to each injection to ensure accurate dosing.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated April 1, 2023, revealed that the resident had diagnoses that included diabetes (a disease that interferes with blood sugar control) and received insulin.
Physician's orders for Resident 8, dated November 15, 2022, included an order for the resident to receive 30 units of Lantus Solostar (a type of glargine insulin used to manage blood sugar levels) 100 units per milliliter (unit/ml) solution pen-injector in the morning for diabetes.
Physician's orders for Resident 8, dated May 13, 2023, included an order for the resident to receive 40 units of Humalog Kwikpen (a pen pre-filled with fast acting insulin) 100 unit/ml solution pen injector two times a day for diabetes.
Physician's orders for Resident 8, dated April 15, 2022, included an order for the resident to receive additional units of Humalog Kwikpen 100 unit/ml solution pen injector before meals, based on the resident's blood sugar levels.
Observations on May 10, 2023, at 7:15 a.m. revealed that Licensed Practical Nurse 1 prepared 30 units of Lantus Solostar solution insulin-pen injector and 41 units of Humalog Kwikpen solution by adding a needle to both insulin pens. Neither pen was primed or given an air-shot prior to the observed administration of both insulins to Resident 8.
Interview with Licensed Practical Nurse 1 after the administration of insulin to Resident 8 revealed she was unsure if priming the insulin pens prior to administration was required.
Interview with the Nursing Home Administrator on May 10, 2023, at 7:45 a.m. confirmed that insulin pens should be primed prior to administration.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart.
Findings ...
Read full inspector narrative →
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart.
Findings include:
The facility's policy regarding the security of the medication cart, dated January 9, 2023, indicated that only licensed nurses, consultant pharmacists and those authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.
Observations on May 10, 2023, at 7:15 a.m. revealed that Licensed Practical Nurse 1 left a medication cart unlocked, unattended and out of sight in the hallway when she entered a resident's room.
Interview with Licensed Practical Nurse 1 on May 10, 2023, at 7:16 a.m. confirmed that her medication cart was not locked, and it should have been.
Interview with the Nursing Home Administrator on May 10, 2023, at 7:45 a.m. confirmed that the medication cart should have been locked when unattended.
28 Pa. Code 211.9(a)(1) Pharmacy services.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ...
Read full inspector narrative →
Based on review of the facility's plans of correction 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 plans of correction for a State Survey and Certification (Department of Health) survey ending June 30, 2022, 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 May 11, 2023, identified repeated deficiencies regarding development of comprehensive care plans, care plan timing and revision, and an effective infection control program.
The facility's plan of correction for a deficiency regarding a failure to ensure that the resident environment remained free from accident hazards, cited during the survey ending June 30, 2022, revealed that the facility developed a plan that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulations regarding development of comprehensive care plans.
The facility's plan of correction for a deficiency regarding a failure to update resident care plans, cited during the survey ending June 30, 2022, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding timing and revision of residents' care plans.
The facility's plan of correction for a deficiency regarding a failure to maintain an effective infection control program, cited during the survey ending June 30, 2022, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plans to ensure ongoing compliance with regulations regarding infection control.
Refer to F656, F657, F880.
28 Pa. Code 201.14(a) Responsibility of licensee.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were follow...
Read full inspector narrative →
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during the administration of medications for two of 40 residents reviewed (Residents 8, 36).
Findings include:
The facility policy regarding medication administration-injectable medications, dated January 9, 2023, indicated that the procedure for administering injections included to apply gloves, select an appropriate site for injection, and cleanse skin with alcohol sponge using a circular motion from center of chosen site until an area of about 3 inches in diameter has been prepared.
The facility's policy regarding medication administration, dated January 9, 2023, indicated that medications are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. Medication should be removed from its source, taking care not to touch the medication with a bare hand.
Physician's orders for Resident 8, dated November 15, 2022, included an order for the resident to receive 30 units of Lantus Solostar (a type of glargine insulin used to manage blood sugar levels) 100 units per milliliter(unit/ml) solution pen-injector in the morning for diabetes. Physician orders, dated May 13, 2023, included an order for the resident to receive 40 units of Humalog Kwikpen (a pen pre-filled with fast acting insulin) 100 unit/ml solution pen injector two times a day for diabetes. Physician's orders, dated April 15, 2022, included an order for the resident to receive additional units of Humalog Kwikpen 100 unit/ml solution pen injector before meals, based on the resident's blood sugar levels.
Observations on May 10, 2023, at 7:15 a.m. revealed that Licensed Practical Nurse 1 administered 30 units of Lantus Solostar insulin and 41 units of Humalog Kwikpen insulin to Resident 8's abdomen without cleansing the resident's injection sites with an alcohol sponge or applying gloves prior to the injections.
Physician's orders for Resident 36, dated March 17, 2022, included an order for the resident to receive two and one-half tablets of carbidopa-levodopa (used to treat Parkinson's) 25 milligrams (mg) - 50 mg tablet. Physician's order, dated February 16, 2023, included for the resident to receive 100 mg of docusate sodium (stool softener) two times a day. Physician's order, dated March 17, 2023, included for the resident to receive 500 mg of levetiracetam (used to treat seizures) two times a day. Physician's order, dated October 21, 2022, included for the resident to receive 20 mg of escitalopram (an antidepressant) every morning. Physician's order, dated March 18, 2023, included for the resident to receive 50 mg metoprolol (used to treat high blood pressure) every morning. Physician's order, dated March 13, 2023, included for the resident to receive one multivitamin with mineral every morning. Physician's order, dated March 1, 2023, included for the resident to receive 20 mg of omeprazole (used to treat acidic stomach) every morning. An order, dated April 25, 2022, included that the resident receive 100 mg of Seroquel (used to treat mental health conditions) two times a day. Physician's order, dated December 11, 2021, included for the resident to receive 550 mg of rifaximin (used to treat irritable bowel syndrome) two times a day.
Observations during medication administration on May 10, 2023, at 7:25 a.m. for Resident 36 revealed that Licensed Practical Nurse 1 touched every medication that was prepared for administration with her bare hands. She poured a dose of medication from each source into her bare hand, picked it off her one hand with her other hand, and placed it in a medication cup. She was observed using a pill cutter to split a carbidopa-levodopa tablet in half and with her bare hands, touched a half table,t and returned it to the tablet bottle. She then administered the medications to the resident.
Interview with Licensed Practical Nurse 1 after the administration of medications to Resident 8 revealed she was unsure if touching medications with bare hands was improper infection control.
Interview with the Nursing Home Administrator on May 10, 2023, at 7:45 a.m. confirmed that gloves should be worn when giving insulin injections, the site of insulin injections should be cleansed with an alcohol wipe prior to administration, and medications were not to be touched with bare hands.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Mar 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for medication parameters for one of three residents reviewed ...
Read full inspector narrative →
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for medication parameters for one of three residents reviewed (Resident 2).
Findings include:
A diagnosis record for Resident 2, dated April 19, 2021, included stroke, morbid obesity, major depressive disorder, COPD (chronic lung disease), and paroxysmal atrial fib (irregular heart rhythm).
Physician's orders for Resident 2, dated December 31, 2021, included an order for Metoprolol, 24-hour extended release, 50 milligrams (mg) daily and that staff were to hold it for a blood pressure less than 90/60 mm/Hg or heart rate less than 60 beats per minute.
Physician's orders for Resident 2, dated January 16, 2023, included an order for Metoprolol, 24-hour extended release to be decreased to 25 mg daily and that staff were to hold it for blood pressure less than 90/60 mm/Hg or heart rate less than 60 beats per minute.
The medication administration record (MAR) for Resident 2, for January, February and March 2023 indicated that he was provided the metoprolol daily. However, there was no documented evidence that staff obtained a blood pressure or checked his heart rate prior the administration as ordered as of March 20, 2023.
Physician's orders for Resident 2, dated March 20, 2023, included an order for the Metoprolol to be discontinued and that Coreg 3.125 mg was to be given daily. A certified registered nurse practitioner's (registered nurse with specialized training) progress note, dated March 22, 2023, indicated that the Metoprolol was discontinued due to Resident 2's atrial fibrillation and dizziness.
Interview with the Director of Nursing on March 23, 2023, at 11:46 a.m. confirmed that there was no documented evidence that the resident's blood pressure and heart rate was checked prior to the administration of Metoprolol as ordered.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- • 40% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding. Review inspection reports carefully.
- • 34 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (35/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
✓ Report will be sent to your email
About This Facility
What is Embassy Of Hillsdale Park's CMS Rating?
CMS assigns EMBASSY OF HILLSDALE PARK an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Embassy Of Hillsdale Park Staffed?
CMS rates EMBASSY OF HILLSDALE PARK's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 40%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Embassy Of Hillsdale Park?
State health inspectors documented 34 deficiencies at EMBASSY OF HILLSDALE PARK during 2023 to 2025. These included: 34 with potential for harm.
Who Owns and Operates Embassy Of Hillsdale Park?
EMBASSY OF HILLSDALE PARK is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by EMBASSY HEALTHCARE, a chain that manages multiple nursing homes. With 74 certified beds and approximately 70 residents (about 95% occupancy), it is a smaller facility located in HILLSDALE, Pennsylvania.
How Does Embassy Of Hillsdale Park Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, EMBASSY OF HILLSDALE PARK's overall rating (2 stars) is below the state average of 3.0, staff turnover (40%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Embassy Of Hillsdale Park?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is Embassy Of Hillsdale Park Safe?
Based on CMS inspection data, EMBASSY OF HILLSDALE PARK has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Embassy Of Hillsdale Park Stick Around?
EMBASSY OF HILLSDALE PARK has a staff turnover rate of 40%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Embassy Of Hillsdale Park Ever Fined?
EMBASSY OF HILLSDALE PARK has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Embassy Of Hillsdale Park on Any Federal Watch List?
EMBASSY OF HILLSDALE PARK is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.