Embassy Of Hillsdale Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Hillsdale, Pennsylvania.
- Location
- 383 Mountain View Drive, Hillsdale, Pennsylvania 15746
- CMS Provider Number
- 395569
- Inspections on file
- 26
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Embassy Of Hillsdale Park during CMS and state inspections, most recent first.
A resident with Alzheimer's and Down's syndrome was repeatedly involved in altercations with another resident who exhibited abusive behaviors. Despite known risks, the facility failed to monitor the resident's wandering, leading to physical confrontations and injuries.
A facility failed to ensure a resident's call bell was within reach, despite the resident's cognitive impairment and need for assistance. The resident was observed in a wheelchair with the call bell out of reach, leading to unmet needs for help. Staff confirmed the call bell should have been accessible.
A facility failed to develop a baseline care plan for a resident's immediate needs within 48 hours of admission. The resident, admitted with a diabetic foot ulcer and peripheral vascular disease, had a PICC for medication administration. Despite physician's orders for PICC maintenance, there was no documented care plan addressing the PICC and related care, as confirmed by the Nursing Home Administrator.
A facility failed to develop a comprehensive care plan for a resident receiving hospice services due to Alzheimer's disease. Despite the completion of a significant change MDS assessment and the resident's admission to hospice, there was no documented care plan addressing the resident's hospice needs, as confirmed by the Nursing Home Administrator.
The facility failed to update care plans for two residents, resulting in outdated interventions. One resident's care plan still included hospice notifications despite discharge, while another's included unnecessary interventions for a stump shrinker and MRSA precautions. These deficiencies were confirmed by the Nursing Home Administrator.
A facility failed to follow physician's orders for a resident's diabetic foot ulcer treatment. The resident's wound care was observed to be incomplete, as the LPN did not cover the wound with an abdominal dressing and rolled gauze as ordered. The LPN was unaware of the requirement, and the Nursing Home Administrator confirmed the oversight.
A facility failed to properly position a resident with Alzheimer's dementia in a Broda chair as per physician's orders. The resident was observed leaning to the right side without the required bilateral bolsters in place. Interviews with the Director of Rehabilitation and the Nursing Home Administrator confirmed the absence of the bolsters, which were necessary to prevent leaning.
A cognitively impaired resident with Alzheimer's dementia, identified as high risk for elopement, was not adequately monitored as there was no documentation verifying the proper functioning of their wanderguard. An incident of increased confusion and wandering occurred, highlighting the facility's failure to ensure the environment was free of accident hazards.
A resident with a PICC line was not administered IV fluids as ordered by the physician. The resident's PICC line was supposed to be flushed with normal saline followed by heparin every 12 hours. However, a nurse only flushed it with normal saline, omitting the heparin. The nurse was unaware of the heparin requirement, which was confirmed by the nursing home administrator.
The facility failed to accurately document the administration of Ativan for a resident, as required by its medication administration policy. Despite being signed out, there was no evidence in the MAR that the medication was given on two occasions. This was confirmed by the DON, highlighting a lapse in medication documentation.
A facility failed to document attempts of non-pharmacological interventions before administering Ativan to a cognitively impaired resident with physical behaviors. Despite a care plan to offer tasks to divert attention, the resident received Ativan multiple times without evidence of non-medication strategies being tried first. This was confirmed by the Nursing Home Administrator.
The QAPI committee failed to address recurring deficiencies related to abuse and neglect, care plan updates, quality of care, and maintaining a safe environment. Despite previous plans of correction, the facility did not achieve compliance with regulations, as identified in the latest survey.
The facility failed to ensure that a physician's order was obtained for blood sugar checks before administering Metformin to a resident. Staff were performing the checks without documented authorization, as confirmed by the Nursing Home Administrator.
The facility failed to follow physician's orders for four residents, including not administering prescribed eye drops, not documenting blood pressure readings before administering hypertension medication, and not notifying the physician of elevated blood sugar levels. These deficiencies were confirmed by the Nursing Home Administrator.
The facility failed to follow wound care recommendations for two residents. One resident with a Stage 3 pressure ulcer was not assessed for an air mattress as requested by a physician. Another resident with a Stage IV pressure ulcer did not receive recommended treatments in a timely manner. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to prevent resident-to-resident altercations involving residents with aggressive behaviors. Multiple incidents occurred where residents with dementia and other diagnoses physically and verbally attacked other residents. The facility did not document any analysis of these incidents to identify triggers or prevent future occurrences, and proper supervision was not maintained.
The facility failed to ensure that medications were properly labeled and dated for three residents. Observations revealed that a multi-dose bottle of Keppra and two Humalog KwikPens were in use without being dated when opened, contrary to the facility's policy and manufacturer's instructions. Interviews with nursing staff and the Nursing Home Administrator confirmed the deficiency.
The facility failed to protect a resident from abuse when another resident with a history of behavioral issues kicked her, causing multiple injuries. The incident was witnessed by a nurse aide and confirmed by the Nursing Home Administrator, indicating a lapse in the facility's abuse prevention policies.
The facility failed to update care plans for three residents to reflect changes in their medication status. One resident's care plan was not updated to show the discontinuation of anticoagulant medication, another's was not revised to indicate the cessation of Cefdinir and Ampicillin, and a third resident's care plan was not updated to reflect the discontinuation of anticoagulant medication. These deficiencies were confirmed through staff interviews and record reviews.
The facility failed to prevent urinary tract infections for a resident with an indwelling urinary catheter. Observations revealed that the resident's catheter tubing was in contact with the floor, violating infection control guidelines.
A resident with diabetes did not have their insulin held as required by physician orders when their blood sugar levels were below 100 mg/dL on multiple occasions. This failure was confirmed by a Regional RN and constitutes a significant medication error.
The facility failed to obtain a physician's order for an invasive procedure to collect a urine specimen for a lab test for a resident. The resident was straight cathed for a dark amber urine sample without documented evidence of a physician's order. The Nursing Home Administrator confirmed the absence of such an order.
The facility's QAPI committee failed to correct recurring deficiencies related to care plan revisions, significant medication errors, and medication storage and labeling. Despite previous plans of correction involving audits and committee reviews, the current survey identified ongoing issues in these areas.
A resident, dependent on staff for showers, did not receive scheduled showers due to staffing shortages. The resident, with cognitive impairment and peripheral vascular disease, was supposed to have showers twice a week. However, documentation showed only two showers were given over a month, with no evidence of offers or refusals. Staff interviews confirmed that being the sole nurse aide on the unit often prevented completion of scheduled showers.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by multiple incidents involving two residents. One resident, who had Alzheimer's disease and Down's syndrome, was at high risk for elopement and had impaired cognitive function. This resident was involved in several altercations with another resident who had dementia and exhibited physically abusive behaviors. On multiple occasions, the first resident was found in the second resident's room, leading to physical confrontations where the second resident grabbed and hit the first resident, causing visible injuries such as fingernail marks on the arm. Despite these incidents, there was no documented evidence that the first resident was being monitored for wandering, which was a known risk factor. The facility's failure to monitor the resident's wandering behavior and prevent these interactions resulted in repeated abusive encounters. The Nursing Home Administrator confirmed the lack of monitoring and the occurrence of multiple abusive interactions between the residents.
Failure to Ensure Call Bell Accessibility for a Resident
Penalty
Summary
The facility failed to provide a reasonable accommodation of needs for a resident by not ensuring that the call bell was within reach. A quarterly Minimum Data Set (MDS) assessment for the resident indicated cognitive impairment and a need for maximum assistance with transfers and toileting. The resident's care plan required staff to ensure the call bell was accessible due to recent falls. However, during an observation, the resident was found sitting in a wheelchair with the call bell out of reach on the bed. The resident reported not receiving help when needed because the call bell was inaccessible. A nurse aide confirmed that the resident could use the call bell and it should have been within reach. The Nursing Home Administrator also confirmed that the call bell should have been accessible to the resident.
Failure to Develop Baseline Care Plan for Resident's PICC
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed for a resident's immediate care needs within 48 hours of admission. Specifically, the facility did not create a baseline care plan for a resident who was admitted with a diabetic foot ulcer and peripheral vascular disease, and who had a peripherally inserted central catheter (PICC) for the administration of fluids and medications. The facility's policy required that a baseline care plan include initial goals based on admission orders and physician's orders, and interventions to address the resident's current needs, including special needs such as intravenous therapy. Upon review, it was found that there was no documented evidence of a baseline care plan addressing the resident's PICC and related care, despite physician's orders detailing specific maintenance requirements for the PICC. These orders included flushing the PICC ports every 12 hours, changing the dressing and other components every seven days, and measuring the external catheter length. The Nursing Home Administrator confirmed the absence of a documented baseline care plan for the resident's PICC care.
Failure to Develop Comprehensive Care Plan for Hospice Services
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 29, who was cognitively impaired, required assistance with care needs, and was receiving hospice services due to a diagnosis of Alzheimer's disease. The facility's policy mandates that a comprehensive, person-centered care plan be developed within seven days of the completion of the required Minimum Data Set (MDS) assessment. However, despite the significant change MDS assessment completed on February 4, 2025, and the resident's admission to hospice services on the same day, there was no documented evidence of a care plan addressing the resident's hospice needs. The deficiency was confirmed during an interview with the Nursing Home Administrator on March 5, 2025, who acknowledged the absence of a documented care plan for Resident 29's hospice services. This oversight is in violation of the facility's policy and relevant state codes, which require the development and implementation of a comprehensive care plan to meet the medical, nursing, mental, and psychosocial needs of residents.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to update and revise the care plans for two residents, leading to deficiencies in their care. For one resident, the care plan still included instructions to notify hospice in the event of cardiac arrest, despite the resident being discharged from hospice care months earlier. This oversight was confirmed by the Nursing Home Administrator, who acknowledged that the care plan should have been updated to reflect the resident's current status. Another resident's care plan included outdated interventions, such as the use of a stump shrinker and contact precautions for a MRSA infection, neither of which were applicable at the time of the assessment. The clinical record lacked evidence that these interventions were still necessary, and the Nursing Home Administrator confirmed that the care plan should have been revised to reflect the resident's current needs. These failures to update care plans were identified during a review of facility policies, clinical records, and staff interviews.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to adhere to physician's orders for wound treatment for a resident with a diabetic foot ulcer and peripheral vascular disease. The resident was admitted with a diagnosis that required specific wound care, including cleansing with normal saline, applying betadine, and covering the wound with an abdominal dressing secured with rolled gauze. However, during an observation of the wound care process, it was noted that the LPN cleansed the wound and applied betadine but left the wound open to air, contrary to the physician's orders. An interview with the LPN revealed a lack of awareness regarding the requirement to cover the wound with an abdominal dressing and rolled gauze. The Nursing Home Administrator confirmed that the physician's orders were not followed, as the wound should have been covered and wrapped. This oversight in following the prescribed wound care regimen constitutes a deficiency in the facility's nursing services, as outlined in 28 Pa. Code 211.12(d)(1)(5).
Failure to Properly Position Resident in Broda Chair
Penalty
Summary
The facility failed to provide proper positioning for a resident, identified as Resident 38, who was cognitively impaired and required assistance with daily care needs. The resident had diagnoses including Alzheimer's dementia and depression. Physician's orders specified that the resident should be seated in a Broda chair with bilateral bolsters to the trunk, a skil-care back pillow, and leg rests during transport. However, observations on two separate occasions revealed that the resident was leaning to the right side with her head on the armrest, indicating that the bolsters were not in place as ordered. Interviews with the Director of Rehabilitation and the Nursing Home Administrator confirmed the absence of the bolsters, which were intended to prevent the resident from leaning.
Failure to Monitor Wanderguard Functioning for High-Risk Resident
Penalty
Summary
The facility failed to ensure that the environment was as free of accident hazards as possible for a resident identified as being at high risk for elopement. The resident, who was cognitively impaired and diagnosed with Alzheimer's dementia, had a care plan that included the use of a wanderguard to mitigate the risk of elopement. Despite this, there was no documented evidence that the wanderguard was checked for proper functioning according to the facility's policy and the resident's care plan. An incident occurred where the resident exhibited increased confusion, expressed a desire to go home, and wandered through the hallways. This episode highlighted the lack of adequate supervision and monitoring of the resident's wanderguard device. The Nursing Home Administrator confirmed the absence of documentation verifying the proper functioning of the wanderguard, which was a requirement per the facility's protocol.
Failure to Administer IV Fluids as Ordered
Penalty
Summary
The facility failed to properly administer intravenous (IV) fluids as ordered by the physician for a resident with a peripherally inserted central catheter (PICC) line. The resident, who was admitted with a diabetic foot ulcer and peripheral vascular disease, had a physician's order to have her PICC line flushed every 12 hours with 5 milliliters (ml) of normal saline followed by 5 ml of heparin. However, during an observation of a PICC dressing change, it was noted that the registered nurse only flushed the PICC line with normal saline and omitted the heparin flush. The registered nurse involved confirmed in an interview that she was unaware of the requirement to flush the PICC line with heparin, as per the physician's orders. The nursing home administrator also confirmed that the nurse should have followed the physician's orders to flush the PICC line with heparin. This oversight in following the prescribed medical orders led to the deficiency noted in the report.
Failure to Document Administration of Controlled Medication
Penalty
Summary
The facility failed to maintain a complete and accurate accounting of controlled medications for one resident. According to the facility's policy on medication administration, staff are required to document the administration of medication on the resident's Medication Administration Record (MAR). However, for one resident, there was no documented evidence that doses of Ativan, an anti-anxiety medication, were administered on two separate occasions, despite being signed out by a nurse. This discrepancy was confirmed by the Director of Nursing during an interview, indicating a lapse in the facility's medication administration and documentation process.
Failure to Attempt Non-Pharmacological Interventions Before Administering Anti-Anxiety Medication
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering as-needed anti-anxiety medication to a resident. The resident, who was cognitively impaired and exhibited physical behaviors directed toward others, had a care plan that included offering tasks to divert attention and minimize disruptive behaviors. Despite this, the resident was administered Ativan, an anti-anxiety medication, multiple times over February and March without documented evidence of non-pharmacological interventions being attempted first. The resident's Medication Administration Record (MAR) showed numerous instances of Ativan being given for agitation, yet there was no documentation in the clinical record to support that non-medication strategies were tried before resorting to medication. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged the lack of documentation for non-pharmacological interventions prior to the administration of Ativan.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address recurring deficiencies effectively, as identified in the current survey ending March 6, 2025. These deficiencies were related to abuse and neglect, updating/revising care plans, quality of care, and maintaining a safe environment free of accident hazards. Despite having developed plans of correction following a previous survey ending April 11, 2024, which included audits and reporting to the QAPI committee, the facility did not achieve compliance with the cited nursing home regulations. Specifically, the facility was unable to implement successful plans to ensure residents were free from abuse and neglect, as cited under F600. Additionally, the facility failed to update or revise residents' care plans adequately, as noted under F657. The quality of care provided did not meet the required standards, as indicated under F684, and the environment was not maintained free of accident hazards, as cited under F689. These repeated deficiencies highlight the QAPI committee's inability to implement effective corrective actions and maintain compliance with state regulations.
Failure to Obtain Physician's Order for Blood Sugar Checks
Penalty
Summary
The facility failed to ensure that physician's orders for blood sugar checks were obtained by a registered nurse for one of the residents reviewed. According to the Pennsylvania Code, registered nurses are required to collect and analyze data to determine nursing care needs and carry out actions that promote well-being. For Resident 24, there was an order for the administration of Metformin at 7:00 a.m. daily. However, the Medication Administration Record for March and April 2024 showed that staff were checking the resident's blood sugar level before administering Metformin without a documented physician's order. This was confirmed by the Nursing Home Administrator, who acknowledged the lack of documented evidence for the blood sugar check order.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by not following physician's orders for four residents. For Resident 12, the facility did not administer prescribed eye drops for the first five doses and failed to notify the physician about the unavailability of the medication, resulting in incomplete treatment. The resident was cognitively intact and required minimal assistance with care, and the issue was confirmed by the Nursing Home Administrator during an interview. For Resident 14, who had a diagnosis of high blood pressure and was at risk for coronary artery disease, the facility did not document blood pressure readings prior to administering Amlodipine as required by the physician's orders. This failure to monitor blood pressure before medication administration was confirmed by the Nursing Home Administrator. Similarly, Resident 24, who also had high blood pressure and was at risk for coronary artery disease, did not have documented blood pressure readings before the administration of Clonidine, as required by the physician's orders. Resident 22, who was cognitively intact and received insulin, had physician's orders to have blood sugar levels checked four times a day and to notify the physician if levels were outside specified parameters. The facility failed to notify the physician when the resident's blood sugar levels exceeded 350 mg/dL on three separate occasions. This lack of documentation and communication was confirmed by the Nursing Home Administrator. These deficiencies indicate a failure to follow physician's orders and ensure proper care and treatment for the residents involved.
Failure to Follow Wound Care Recommendations
Penalty
Summary
The facility failed to follow recommendations from a wound consultation for two residents. Resident 3, who was cognitively intact and had a Stage 3 pressure ulcer, was supposed to be assessed for an air mattress to assist with pressure distribution as per a physician's progress note. However, observations revealed that the resident did not have an air mattress, and there was no documented evidence that an assessment for the air mattress had been conducted. The Nursing Home Administrator confirmed that the resident was never assessed for an air mattress as requested by the physician. Resident 30, who was also cognitively intact and had a Stage IV pressure ulcer to the coccyx, was recommended to have the wound cleansed with 0.125 percent Dakin's solution and have collagen and silver alginate applied twice a day. Despite these recommendations being documented on March 22, 2024, the treatment was not started until March 30, 2024. The Nursing Home Administrator confirmed that the treatments were not completed as recommended by the wound clinic. These failures indicate a lack of adherence to prescribed wound care protocols for both residents.
Failure to Prevent Resident-to-Resident Altercations
Penalty
Summary
The facility failed to ensure that the residents' environment remained free of accident hazards caused by residents with aggressive behaviors. Resident 14, who had a diagnosis of dementia and a history of abusive behavior, was involved in multiple incidents of aggression towards other residents. On December 25, 2023, Resident 14 threatened and physically attacked Resident 58. On January 5, 2024, Resident 14 made verbal threats during breakfast, and on March 20, 2024, Resident 14 slapped Resident 63 in the hallway. Despite these incidents, there was no documented evidence that the facility analyzed the triggers and circumstances leading to these altercations. Resident 117, diagnosed with dementia and schizophrenia, also exhibited aggressive behaviors. On July 16, 2023, Resident 117 hit Resident 44, and on September 8, 2023, Resident 117 kicked Resident 58, causing her to fall, and later punched Resident 44. The social worker attempted to manage Resident 117 by taking him to his office, but the resident left unsupervised when the social worker answered a phone call. The facility did not document any analysis of the incidents to identify key times, places, or triggers for Resident 117's aggressive behavior. Resident 58, who had a diagnosis of Alzheimer's disease and a potential for physical aggression, was also involved in altercations. On March 19, 2024, Resident 58 hit Resident 61 twice. The facility did not provide evidence of analyzing these incidents to prevent future occurrences. The Nursing Home Administrator confirmed the incidents and acknowledged that proper supervision was not maintained, particularly in the case of Resident 117 when the social worker left him unattended.
Failure to Properly Label and Date Medications
Penalty
Summary
The facility failed to ensure that medications were properly labeled and dated for three residents. The facility's policy, dated March 14, 2024, required that all pre-filled pens and multi-dose vials of medication be labeled with the date opened and the initials of the healthcare professional, and discarded within 28 days unless otherwise specified by the manufacturer. However, during observations on April 11, 2024, it was found that a multi-dose bottle of Keppra for Resident 10 and a Humalog KwikPen for Resident 11 were in use and not dated when opened. Similarly, on April 9, 2024, a Humalog KwikPen for Resident 45 was also found in use without being dated when opened. Interviews with the nursing staff confirmed that these medications should have been dated when first opened, as per the facility's policy and the manufacturer's instructions. Resident 10 had a physician's order for Keppra solution to be taken twice daily, while Residents 11 and 45 had orders for Humalog KwikPen to be administered subcutaneously before meals and at bedtime per sliding scale. The failure to date these medications when opened was confirmed by the Nursing Home Administrator during an interview on April 11, 2024. This deficiency was cited under 28 Pa. Code 211.9(a) Pharmacy Services.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving Resident 58 and Resident 117. Resident 117, who had a history of dementia and schizophrenia, exhibited behaviors such as wandering, abusive language, and sexually inappropriate behaviors. On the day of the incident, Resident 117 attempted to enter Resident 58's room, and when Resident 58 resisted, Resident 117 kicked her, causing her to fall and sustain multiple bruises and abrasions. The incident was witnessed by a nurse aide who confirmed that Resident 117 kicked Resident 58, leading to her injuries. Resident 58, who had a diagnosis of Alzheimer's disease, was found on the floor with bruises on her right palm, right elbow, right wrist, and an abrasion on her right buttock. The facility's policy on abuse, which states that abuse, neglect, and exploitation of residents will not be tolerated, was not effectively implemented in this case. The Nursing Home Administrator confirmed the incident, highlighting a failure in protecting residents from abuse as required by the facility's policies and state regulations.
Failure to Update Care Plans for Three Residents
Penalty
Summary
The facility failed to review and revise care plans for three residents as required. Resident 1's care plan was not updated to reflect the discontinuation of anticoagulant medication, despite the resident's significant change Minimum Data Set (MDS) assessment indicating that the resident was not receiving such medication. This was confirmed by the Nursing Home Administrator during an interview. Similarly, Resident 3's care plan was not updated to indicate that the resident was no longer receiving Cefdinir and Ampicillin for a wound infection, even though the medication administration records showed that the resident had stopped receiving these medications. This oversight was also confirmed by the Nursing Home Administrator during an interview. Additionally, Resident 51's care plan was not revised to reflect the discontinuation of anticoagulant medication, despite the resident's annual MDS assessment and current physician's orders indicating that the resident was not receiving such medication. This failure was confirmed by a Regional Registered Nurse during an interview. The facility's policy required care plan revisions to be made when a resident experiences a status change, but this policy was not followed for the three residents in question.
Failure to Prevent Urinary Tract Infections
Penalty
Summary
The facility failed to provide appropriate care to prevent urinary tract infections for a resident with an indwelling urinary catheter. The facility's policy, dated March 14, 2024, required adherence to infection control guidelines when providing catheter care. A significant change Minimum Data Set (MDS) assessment for the resident, dated January 19, 2024, indicated that the resident was moderately cognitively impaired, required assistance for daily care activities, and had a neurogenic bladder. Physician's orders from December 28, 2023, specified the use of an 18 French urinary catheter with a 10 cc balloon. Observations on April 8 and April 10, 2024, revealed that the resident's catheter tubing was in contact with the floor while the resident was in a wheelchair. This was confirmed by a registered nurse and the Nursing Home Administrator during interviews on April 10, 2024. The contact of the catheter tubing with the floor was a clear violation of the facility's infection control guidelines, contributing to the failure to prevent urinary tract infections for the resident.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
The facility failed to ensure that it was free from significant medication errors for one of the residents reviewed. Resident 22, who had a diagnosis of diabetes and was receiving insulin, had specific physician orders to hold insulin if the resident's blood sugar was less than or equal to 100 mg/dL. However, the facility did not adhere to these orders on multiple occasions. Specifically, on March 4, 6, 18, and 19, 2024, and April 1, 2024, Resident 22's blood sugar levels were below 100 mg/dL, but there was no documented evidence that the insulin was held as required by the physician's orders. An interview with the Regional Registered Nurse confirmed that the insulin was not held on the dates mentioned, despite the resident's blood sugar levels being below the threshold specified in the physician's orders. This failure to follow the physician's orders constitutes a significant medication error, as the facility's policy on medication administration clearly states that medications should be administered in accordance with physician orders.
Failure to Obtain Physician's Order for Invasive Procedure
Penalty
Summary
The facility failed to obtain a physician's order for an invasive procedure to collect a urine specimen for a laboratory test for one resident. A quarterly Minimum Data Set (MDS) assessment for the resident indicated that the resident was understood and understands. Physician's orders included an order to obtain a urine culture and sensitivity test. However, a progress note revealed that the resident was straight cathed for a dark amber urine sample, which was sent to the lab, without documented evidence of a physician's order for the catheterization. The Nursing Home Administrator confirmed the absence of such an order.
Repeated Deficiencies in Care Plans and Medication Management
Penalty
Summary
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. The current survey 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. These deficiencies were also noted in the previous survey ending May 11, 2023, indicating that the QAPI committee's corrective actions were ineffective. Specifically, the facility's plan of correction for revising care plans included completing audits and reporting the results to the QAPI committee, but the current survey revealed ongoing issues in this area. Similarly, the plan to prevent significant medication errors involved audits and QAPI committee reviews, yet the current survey found that residents were still experiencing significant medication errors. Additionally, the plan to ensure proper storage and labeling of medications was not successfully implemented, as evidenced by the repeated deficiencies in this area during the current survey.
Failure to Provide Scheduled Showers Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively impaired and dependent on staff for showers, received showers as scheduled. The resident, diagnosed with peripheral vascular disease, was supposed to receive showers every Wednesday and Saturday according to the facility's schedule. However, a review of the bathing documentation revealed that the resident only received two showers between February 20, 2024, and March 19, 2024. There was no documented evidence that the resident was offered or refused showers weekly as per the care plan. Interviews with staff members, including nurse aides and an LPN, indicated that staffing shortages on the North Shore unit contributed to the failure to provide scheduled showers. Nurse aides reported being unable to complete scheduled showers due to being the only staff available on the unit, which was confirmed by the Nursing Home Administrator. This staffing issue was a common occurrence, leading to the resident not receiving the necessary care as outlined in their care plan.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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