Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of Hillsdale Park during CMS and state inspections, most recent first.
Hot Water Temperatures Exceeded Safe Limits: The facility failed to keep sink water temperatures within safe limits after surveyors found multiple bathroom sinks measuring above the facility policy maximum, including water that felt hot to the touch. An LPN and the Maintenance Director both confirmed the water was too hot, and the Maintenance Director stated he had not been notified of any resident, staff, or visitor concerns about the water temperature.
A resident who was cognitively impaired, needed staff help with daily care, and used a scoot and go wheelchair had both armrests wrapped with black tape on repeated observations. The NHA confirmed the wheelchair armrests should have been repaired or replaced, showing the facility did not maintain the resident’s wheelchair in good repair.
A resident with cognitive impairment and dementia had a witnessed fall, sustained injuries, and was transferred to the hospital with altered mental status, a head injury, and seizures. The facility had no documented evidence that the resident and legal guardian were notified in writing of the reason for the transfer or that the ombudsman was notified of the hospitalization.
A resident with chronic diarrhea and ulcerative colitis had physician orders for Lamotil PRN and Mesalamine BID, and the resident reported ongoing diarrhea and continued medication use. Surveyors found no documented individualized care plan with measurable goals or timetables to address the resident’s condition, and the NHA confirmed the care plan was missing.
A resident with HTN and HF had an order for Coreg 12.5 mg BID with hold parameters for low BP or a pulse under 60 bpm. MAR review showed multiple times when the resident's pulse was below 60, but there was no documented evidence that the medication was held as ordered, and the NHA confirmed the missing documentation.
The facility failed to maintain accountability for a resident’s controlled medication. A resident receiving lorazepam for anxiety had remaining doses documented on the narcotic sheet, but there was no evidence that the unused medication was destroyed and verified by two licensed nurses as required by policy.
An LPN left a medication cart unlocked and unsupervised inside the med room while the med room door was held open with a piece of wood. The LPN confirmed both the cart and the door should have been locked, and the NHA confirmed the cart should have been locked when unattended and the med room door should have been closed and locked.
A resident with cognitive impairment and dementia had a physician order and care plan for bed and chair alarms per family request, and was observed with an alarm in place. However, TARs and nurse aide documentation for multiple months contained no entries showing the alarms were in place, and the NHA confirmed the clinical record lacked this documentation.
QAPI committee oversight was ineffective in addressing recurring deficiencies. Prior POCs called for audits and QAPI review, but the current survey found repeated issues with individualized care planning (F656), quality of care (F684), accident hazard prevention (F689), and controlled med accountability (F755), showing the committee did not successfully implement the planned quality assurance measures.
An infection control deficiency occurred when an LPN administered eye drops, removed gloves, and then prepared meds for another resident without hand hygiene, while another LPN picked up a dropped pill with bare hands before giving it to a resident. During wound care for a resident with diabetes, dementia, and pressure ulcers, an LPN did not wear the required gown for EBP, changed gloves multiple times, and left the room without hand hygiene after completing care.
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.
Hot Water Temperatures Exceeded Safe Limits
Penalty
Summary
The facility failed to maintain an environment free of potential safety hazards related to hot water temperatures. A facility policy dated April 3, 2025, stated that water temperatures would be set to no more than 120 degrees Fahrenheit or the state's allowable maximum. During observation in a bathroom sink in a resident room on February 19, 2026, at 12:45 p.m., the water felt hot to the touch and measured 120.3 degrees F. An LPN present at the time stated the water was hot to touch and was unaware of any reported concerns from residents, staff, or visitors that the water was too hot. Additional observations by the Maintenance Director showed inconsistent and excessive temperatures in multiple sinks. A shared bathroom sink between rooms measured 115 degrees F, a hallway bathroom sink across from a resident room measured 131 degrees F, and a bathroom sink in another resident room measured 121.6 degrees F. The Maintenance Director confirmed the water was too hot and stated it should be between 100 and 110 degrees F. He also stated he had not been notified of any concerns by residents, staff, or visitors that the water was too hot. The Nursing Home Administrator confirmed the water temperatures in residents' rooms should not have been that high.
Wheelchair Not Kept in Good Repair
Penalty
Summary
The facility failed to provide a clean and homelike environment by not ensuring that Resident 61’s wheelchair was in good repair. Resident 61’s quarterly MDS dated February 1, 2026, indicated the resident was cognitively impaired, required staff assistance for daily care tasks, used a scoot and go wheelchair, and had diagnoses including paranoid schizophrenia and dementia. Observations on February 17, 2026, and again on February 19, 2026, showed that the leather on both armrests of the resident’s scoot and go wheelchair had black tape wrapped around them. The Nursing Home Administrator confirmed on February 19, 2026, that the wheelchair armrests should have been repaired or replaced.
Failure to Notify Resident Representative and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to notify the resident and/or the resident's representative in writing regarding the reason for transfer to the hospital and failed to notify the ombudsman of the transfer for one resident. The resident had a significant change MDS assessment indicating cognitive impairment, need for staff assistance with daily care needs, and diagnoses including dementia. After a witnessed fall in the hallway, the resident sustained a skin tear to the left ring finger and a reddened area on the left side of the forehead and was transferred to the hospital, where she was admitted with altered mental status, a head injury, and seizures. Review of the clinical record found no documented evidence that the resident and legal guardian were notified in writing of the purpose for the transfer or that the ombudsman was notified of the hospitalization, and the Nursing Home Administrator confirmed this during interview.
Failure to Develop Care Plan for Chronic Diarrhea and Ulcerative Colitis
Penalty
Summary
The facility failed to develop and implement an individualized care plan for one resident who had chronic diarrhea and ulcerative colitis. The facility policy dated April 3, 2025 required a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident’s medical, nursing, mental, and psychosocial needs. A quarterly MDS assessment dated January 2, 2026 showed the resident was cognitively intact, was understood, could understand, and required supervision with care needs. The resident told the surveyor that she had been having diarrhea for a while and still had to take medication. Records showed a nursing note documenting a colonoscopy and physician orders for Lamotil as needed for diarrhea and Mesalamine twice daily for ulcerative colitis. Survey review found no documented evidence that a care plan was developed to address the resident’s chronic diarrhea and ulcerative colitis, and the Nursing Home Administrator confirmed that the resident did not have a care plan for these conditions and medications.
Failure to Follow Hold Parameters for Cardiac Medication
Penalty
Summary
The facility failed to ensure that physician's orders were followed for Resident 68, who was cognitively intact and had diagnoses including hypertension and heart failure. The resident had an order for Coreg 12.5 mg twice daily for hypertension, with instructions to hold the medication if blood pressure was below 90/60 mmHg or pulse was less than 60 bpm. Review of the MAR for October and November 2025 and February 2026 showed multiple instances when the resident's pulse was documented as less than 60 bpm at 7:00 a.m., but there was no documented evidence that Coreg was held as ordered on those dates. The Nursing Home Administrator confirmed that there was no documented evidence that the medication was held as ordered.
Controlled Medication Disposal Not Documented
Penalty
Summary
The facility failed to ensure accountability of controlled medications for one resident receiving lorazepam for anxiety. The resident had an order for 0.5 mg of lorazepam once daily, and the controlled narcotic sheet showed that 29 doses were received on December 1, 2025. By December 22, 2025, the sheet showed 9 doses remaining, but there was no documented evidence that the remaining 9 doses were destroyed and verified by two licensed nurses as required by the facility policy for controlled medication disposal. The policy stated that destruction/disposal of controlled medications must include a licensed nurse and a licensed pharmacist or authorized nurse supervisor, with documentation of the resident name, medication, prescription number, amount destroyed, date of disposition, and signatures of both persons disposing of the medication. The Nursing Home Administrator confirmed that there was no documented evidence that the resident's lorazepam was destroyed by two licensed nurses per policy.
Unsecured Medication Cart and Open Medication Room Door
Penalty
Summary
The facility failed to ensure that medications were properly secured in a medication cart. The facility policy dated April 3, 2025 stated that medication carts would be maintained and access controlled for licensed and approved personnel. During an observation on February 19, 2026 at 2:11 p.m., an LPN was observed walking out of the medication room on the ambulatory care unit, leaving the medication cart unlocked and unsupervised inside the medication room while the medication room door was held open with a piece of wood. In an interview moments later, the LPN confirmed that the medication cart was unlocked and unsupervised and that the medication room door was held open with a piece of wood, and stated that both should have been locked. The NHA later confirmed that the medication cart should have been locked when unsupervised and that the medication room door should have been closed and locked when the room was unsupervised.
Incomplete Documentation of Bed and Chair Alarms
Penalty
Summary
The facility failed to ensure that Resident 5's clinical record was complete and accurately documented. Resident 5's significant change MDS assessment dated January 16, 2026 indicated cognitive impairment, need for staff assistance with daily care needs, and a diagnosis of dementia. A physician's order and care plan dated September 12, 2025 directed that the resident use a bed and chair alarm per the family's request. On February 17, 2026, the resident was observed in the hallway in a chair with an alarm in place. However, review of the TARs and nurse aide documentation for November and December 2025 and January and February 2026 showed no staff documentation that the resident's bed and chair alarms were in place. The Nursing Home Administrator confirmed on February 20, 2026 that the clinical record did not contain documentation indicating the chair and bed alarms were in place.
QAPI Committee Failed to Address Recurring Deficiencies
Penalty
Summary
The facility's QAPI committee failed to maintain compliance with nursing home regulations and did not effectively ensure that plans to improve the delivery of care and services addressed recurring deficiencies. The report states that the facility had prior plans of correction from a State Survey and Certification survey ending March 6, 2025, which included quality assurance systems and audits to be reviewed by the QAPI committee, but the current survey ending February 20, 2026, found repeated deficiencies in individualized care planning, quality of care, accident hazard prevention, and controlled medication accountability. For the deficiency cited under F656, the facility's prior plan of correction called for audits and reporting to the QAPI committee, but the current survey found that the committee failed to successfully implement the plan to ensure care plans were developed for residents' individual needs. For F684, F689, and F755, the report similarly states that the facility's QAPI committee was ineffective in maintaining compliance with requirements for quality of care, keeping the resident environment free from accident hazards, and correcting deficient practices related to controlled medication accountability.
Infection Control Lapses During Medication Administration and Wound Care
Penalty
Summary
The facility failed to maintain professional infection prevention and control practices during medication administration and wound care for three residents. The facility policy stated that hand hygiene must be performed before donning gloves and immediately after removing gloves, that gloves do not replace hand hygiene, and that medications must be handled in a manner that prevents contamination or infection. The policy on enhanced barrier precautions required gowns and gloves for high-contact care activities, including wound care for residents with wounds or indwelling medical devices. During medication administration for one resident, an LPN donned gloves to administer eye drops, removed the gloves, and then went to the medication cart to prepare and administer medications to another resident without performing hand hygiene. The LPN stated she did not think hands had to be cleaned between every resident and said she was careful not to touch anything with bare hands. During medication preparation for another resident, an LPN dropped a pill on the medication cart, picked it up with bare hands, and placed it in a medication cup with other medications before administering it to the resident. The LPN confirmed she should not have touched the medication with bare hands. During wound care for a resident with diabetes, dementia, and pressure ulcers, an LPN provided care to wounds on the right ankle and left heel. She donned and removed gloves multiple times, washed her hands once during the treatment, but did not wear a gown despite the resident having an order for enhanced barrier precautions during wound care. She also exited the room after completing wound care without performing hand hygiene. The LPN stated she should have worn a gown but did not because there were no supplies on the unit, and acknowledged she did not wash her hands after completing the wound care before leaving the room.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 155 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hillsdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Haida Nursing And Rehab | 11 mi | ★★★★★ | 11 | 0 |
| Mulberry Healthcare And Rehabilitation Cent | 14.4 mi | ★★★★★ | 34 | 0 |
| Communities At Indian Haven, | 17.8 mi | ★★★★★ | 17 | 0 |
| Beacon Ridge | 18.2 mi | ★★★★★ | 25 | 0 |
| Julia Pound Care Center | 18.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.