Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Huntingdon Park during CMS and state inspections, most recent first.
Medication orders were not followed for three residents. One resident with HTN and heart disease did not have BP checks before atenolol doses and received doxazosin when BP was below the hold parameter or not obtained. Another resident with Alzheimer’s received an incorrect Rexulti dose, and a resident with DM had multiple Humalog doses charted as not required; the DON confirmed the orders were not administered as ordered.
Menu Not Followed for Pureed Meal Service: The facility did not follow the pre-approved lunch menu for a pureed diet. A resident reported pureed food did not taste good, and another said it tasted off. The posted regular menu listed BBQ glazed meatloaf, but the pureed tray contained a pureed angus beef patty instead of pureed BBQ meatloaf, and only the regular menu was posted outside the dining rooms. The DON and consultant dietitian stated the pureed foods were prepared off-site, while the NHA said the facility had no control over kitchen services.
Food Storage, Thawing, and Dishwashing Sanitization Deficiencies: Surveyors observed uncovered cookies and pureed pears stored open to air on a tray cart in the cooler, and frozen chicken thighs thawing in a dry sink instead of the cooler. Surveyors also observed a converted dishwasher being used with chemical sanitization, but sanitizer test strips remained white with no indication of sanitizer in the water while dietary staff were washing dishes.
Exposed urinary catheter bags: Two cognitively intact residents with indwelling urinary catheters were observed with their drainage bags visible to others, including in the hallway and activity areas, rather than covered with privacy or dignity bags. An aide, an LPN, and the DON confirmed the bags were exposed and should have been covered.
Missing floor tiles and unsanitary shower areas were observed in a resident’s room and in a second-floor shower room. The resident was cognitively intact and used a wheeled walker, and surveyors found a large missing tile in the room plus several missing shower-floor tiles around the drain with a slimy black removable substance present.
Failure to Investigate Resident Food Grievances: Residents voiced concerns in food committee meetings that there was too much chicken on the menu, but there was no documented evidence the concerns were addressed. The menu cycle showed chicken served 15 times in 21 days, and the Dietary Director was unaware of the complaints while the Activity Director did not complete a grievance form. The NHA confirmed the concerns should have been documented and escalated if there was no response.
A resident with severe cognitive impairment and diagnoses including osteoarthritis of the knee and intellectual disabilities was observed in a broda chair with the rear wheel locks engaged. The LPN stated the brakes were applied to keep the resident from rolling backward because the building was old and uneven, and confirmed the locks prevented movement. The resident was later observed self-propelling at the dining table, and the Regional Consultant/Acting DON could not find documentation showing the chair had been locked.
Failure to assess and plan for PTSD triggers. A resident with depression, anxiety, and PTSD was cognitively impaired and dependent on staff for daily care needs, but the record had no documented evidence of identified PTSD triggers, measures to prevent or minimize triggers, or a PTSD care plan. The Acting DON stated the facility did not assess for triggers or create a PTSD care plan because the family said they did not believe the resident had PTSD.
The facility failed to complete annual performance evaluations for three nurse aides reviewed. Personnel files showed no evidence of updated evaluations for Nurse Aide 4, Nurse Aide 5, and Nurse Aide 6 since 2024, and the NHA confirmed the evaluations had not been completed and should be done annually.
Medication storage practices were not followed when insulin and diabetes medications in two med carts were found either undated or past the 28-day discard period. An LPN and the DON confirmed that a Novolog pen, Ozempic pen, Lantus pen, and Basaglar pen were not properly dated or discarded as required; the affected residents had diabetes mellitus type 2, and some also had cognitive impairment, dementia, heart failure, or stroke-related weakness.
Failure to Honor Resident Food Preference: A cognitively intact resident who needed set-up assistance and was independent with eating after set-up received broccoli on her lunch tray even though her food preference records and meal ticket showed she disliked broccoli. The resident stated she did not like broccoli, and the DON confirmed she should have been offered another vegetable option. The resident’s care plan also noted recent inadequate intake and frequent meal refusals, with an intervention to provide favorite foods within diet.
QAPI Committee Failed to Correct Repeated Deficiencies: The facility’s QAPI committee did not successfully implement prior audit-based plans of correction tied to repeated citations for quality of care, food storage/prepare/serve-sanitary, and infection control. The current survey found recurring deficiencies under F684, F812, and F880 despite earlier plans to review audit results through QAPI.
The facility failed to post infection control signage at the room entrances for three residents with Foley catheters. Each resident had MDS, care plan, and MD order documentation showing an indwelling urinary catheter, but observations found no enhanced barrier precaution signs posted. An LPN and the Infection Control Nurse both confirmed the missing signage.
A resident with cirrhosis on hospice care and a PleurX catheter experienced ongoing leakage from the liver catheter, prompting the resident’s spouse to request transfer to the ER for evaluation. Nursing staff contacted a CRNP, who consulted with hospice and determined the resident did not need ER care and could be seen by hospice in the facility. Despite the spouse’s continued insistence on ER transfer, staff informed her they could not provide an order and that leaving would be against medical advice, rather than facilitating the requested transfer. A Regional RN later confirmed that the resident should have been sent to the hospital when the responsible party requested it, demonstrating a failure to honor the resident representative’s right to make treatment decisions.
Surveyors found that a resident did not receive a full course of ordered Cipro when the facility failed to adjust the antibiotic schedule after two missed doses, resulting in only nine days of therapy instead of the prescribed ten. In addition, another resident, initially assessed with intact skin and placed on a preventive zinc oxide regimen, later developed non-intact skin with treatment in place to the buttocks and coccyx, but there was no documented assessment of the skin change or notification of the wound nurse at that time; a subsequent assessment documented a closed abrasion and blanchable redness.
A resident with confusion, extensive ADL needs, and a right heel pressure ulcer did not receive wound care consistent with updated provider orders. After a CRNP changed the treatment from Gentamicin to Calmoseptine and a corresponding physician order specified cleansing the right foot, applying Calmoseptine, and using a heel cup with daily changes, staff documentation on the TAR showed they continued to apply Gentamicin in the evenings while also using Calmoseptine in the mornings. The Regional Nurse confirmed Gentamicin should have been discontinued, but staff instead applied both ointments rather than following the current order.
Surveyors found a full portable oxygen tank lying unsecured on a metal stretcher parked in a hallway outside residents’ rooms, contrary to facility policy requiring portable oxygen tanks to be stored safely in an upright position. The stretcher and tank were within reach of residents. An LPN acknowledged the tank should not have been stored on the stretcher in the hallway and was unsure why the stretcher was there, and the Regional Nurse confirmed the tank should have been stored securely elsewhere.
A resident with heart failure and hypertension did not receive prescribed Metoprolol Succinate for several months after a physician's order to decrease the dosage was not entered into the MAR, resulting in the medication not being administered as required.
A resident who was cognitively impaired, incontinent, and at risk for pressure ulcers developed a fluid-filled blister on the abdomen. Physician orders required a protective barrier to be applied twice daily, but review of treatment records showed no documentation that these treatments were completed as ordered. The Nursing Home Administrator confirmed the absence of documentation.
The facility did not follow physician orders for insulin administration for a resident with diabetes, administered insulin to another resident outside the manufacturer's recommended time frame, and failed to provide wound care as recommended by a consultant for a resident with frostbite wounds. These deficiencies were confirmed through record review and staff interviews.
A resident with a Stage 3 pressure ulcer did not receive wound care treatments as recommended by a wound consultant, including missed applications of collagen and bacitracin ointment on multiple occasions, as confirmed by the DON.
Surveyors identified multiple deficiencies in food storage and labeling, with uncovered and undated food items in both the cooler and freezer, and improper storage of scoops in ingredient bins. Dietary staff were observed handling food without fully covered hair, and kitchen equipment and shelving were found to be dusty and unclean, all in violation of facility policy.
A nurse aide failed to promptly report an incident where another aide yelled at a cognitively impaired resident and made a demeaning comment during care. The delay in reporting the suspected verbal abuse was not in accordance with facility policy, which requires immediate notification to administration.
A resident receiving anticoagulation therapy did not have a physician-ordered INR blood test completed as required. Despite prior adjustments to the resident's medication following a critically high PT/INR, there was no documentation that the subsequent ordered lab was performed, as confirmed by facility administration.
A resident with an indwelling catheter, Stage 4 pressure ulcer, and wound infection did not have Enhanced Barrier Precautions (EBP) implemented upon admission, despite facility policy and federal guidelines requiring gown and glove use for residents with chronic wounds or indwelling devices. EBP was not documented or ordered until after contact precautions for an MDRO were discontinued, resulting in a failure to follow infection control protocols.
The facility did not submit required direct care staffing information for fiscal quarter one of 2024, as mandated by the ACA. The submission, due by the 45th day after the quarter's end, was confirmed missing during an interview with the Nursing Home Administrator.
The facility failed to update care plans for three residents, leading to discrepancies between documented care needs and actual care provided. A resident's care plan was not updated to reflect the discontinuation of a midline and antibiotic therapy. Another resident's care plan did not reflect the end of isolation precautions and antibiotic therapy. Additionally, a third resident's care plan lacked documentation for a wound vac requirement. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to follow physician orders for a resident's IV line care, including not flushing the midline catheter with saline before and after administering levofloxacin and neglecting to change IV line dressings and caps as required. The resident was receiving IV medications for a MRSA infection, and the lack of documentation confirmed these deficiencies.
The facility failed to maintain sanitary conditions for ice preparation and storage, with a dark substance found in the second-floor ice machine, and did not adhere to food storage standards, with unsealed cheese and expired rice in the kitchen. The Assistant Maintenance Director and Dietary Manager confirmed these deficiencies.
A resident with Alzheimer's and dementia, requiring extensive assistance, was found with unclean fingernails despite the facility's policy for regular nail care. Observations in May revealed the resident's nails extended beyond the fingertips with a dark substance underneath, indicating a failure in providing necessary personal grooming and hygiene services.
A resident with a history of sexually inappropriate behavior was involved in an incident due to the facility's failure to ensure functioning safety interventions. Despite a care plan revision to include a motion alarm on the resident's door, observations revealed the alarm was not functioning properly, and there was no documented evidence of monitoring its function.
The facility failed to maintain accountability for controlled medications for two residents. For one resident, doses of oxycodone were signed out but not documented as administered in the MAR. Similarly, another resident had doses signed out without documentation of administration. These discrepancies were confirmed by the Nursing Home Administrator, indicating a failure to adhere to the facility's medication administration policy.
The QAPI committee at the facility failed to effectively address recurring deficiencies related to care plan updates, grooming and hygiene, and accident hazard prevention. Despite previous plans of correction, the same issues persisted, indicating insufficient implementation of corrective measures.
Medication orders not followed for antihypertensive, antipsychotic, and insulin administration
Penalty
Summary
The facility failed to ensure that physician orders for medication administration were followed for three residents. Facility policy required medications to be administered as ordered by the physician and in accordance with professional standards of practice. For one resident with cognitive impairment, high blood pressure, and heart disease, an order required atenolol 50 mg daily at 8:00 p.m. with the medication to be held if systolic blood pressure was less than 110 mm/Hg, but blood pressures were not taken before the evening doses from November 28, 2025 through March 3, 2026. The same resident also had an order for doxazosin mesylate 1 mg twice daily with instructions to hold the medication if systolic blood pressure was less than 110 mm/Hg. The MAR showed doses were given when blood pressures were below that parameter, including when the blood pressure was 80/52 mm/Hg, 107/43 mm/Hg, 106/76 mm/Hg, and 104/58 mm/Hg, and one dose was given when no blood pressure was taken. The Regional Consultant/Acting DON confirmed that the atenolol and doxazosin mesylate were not administered as ordered. Another resident with Alzheimer’s disease was ordered Rexulti 3 mg daily, but the MAR showed the resident received 3.5 mg daily for 13 days before the practitioner was notified and the order was corrected. A third resident with diabetes mellitus and insulin use had orders for Humalog at 8:30 a.m., 12:30 p.m., and 5:30 p.m., but the MAR showed multiple doses coded as insulin not required on numerous dates in January and February 2026. The Regional Consultant/Acting DON confirmed the insulin orders were not administered as ordered, there were no parameters for the insulin, and the physician was not notified when insulin was not given.
Menu Not Followed for Pureed Meal Service
Penalty
Summary
The facility failed to follow its pre-approved planned menu for the lunch meal service. The posted regular menu for Wednesday lunch listed BBQ glazed meatloaf, mashed potatoes, green beans, fruit cup, peanut butter brownie, 2% milk, and unsweetened iced tea, but observations of a test tray showed that the pureed meat served was not pureed BBQ meatloaf; it was a pureed angus beef patty instead. The pureed menu indicated pureed BBQ meatloaf, pureed mashed potatoes, pureed green beans, applesauce, and chocolate pudding, and the meatloaf and pureed angus beef did not taste similar. Only the regular menu was posted in the hallway outside the second-floor dining room and the third-floor dining room. Resident interviews reflected dissatisfaction with the pureed meals, with one resident stating her pureed food never tastes good and another stating her pureed food tastes off and not right. The Dietary Director stated that all pureed food was frozen and that the only pureed food made on site was mashed potatoes; if beef was on the menu, residents requiring pureed diets received frozen pureed beef because that was what was available, and the pureed beef was not pureed meatloaf. The Consultant Dietitian stated that menus were completed by a food service company and that food was provided from an off-site commissary where it is prepared, and the Nursing Home Administrator stated the facility did not have any control over the kitchen services.
Food Storage, Thawing, and Dishwashing Sanitization Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. A facility policy dated July 10, 2025 stated that foods stored on ladder or speed racks must be fully covered to prevent contamination from airborne contaminants and dripping condensation, either by using a bag that covers the entire cart or by covering each item individually. On March 2, 2026, surveyors observed an uncovered wheeled tray cart in the walk-in cooler with individual cookies on Styrofoam plates that were not wrapped and were open to air, as well as individual servings of pureed pears that were also not wrapped and open to air. The Dietary Director confirmed that food should be covered. During the same observation, approximately nine packages of frozen chicken thighs in sealed plastic bags were found in a dry sink thawing for the next day's meal. The Dietary Director stated that the chicken should have been thawing in the cooler and directed staff to move it there because it should not have been left in the sink. On March 5, 2026, surveyors observed a high-temperature dishwasher that had been converted to a low-temperature dishwasher with chemical sanitization. Two dietary staff were washing dishes, but multiple attempts by the Dietary Director to test the sanitizer level showed the test strips remained white with no indication of sanitizer in the water. The Dietary Manager stated the chemicals had been checked the day before during service, believed the issue was with the test strips, and had staff prepare the three-basin sinks for hand washing.
Exposed urinary catheter bags
Penalty
Summary
The facility failed to maintain the dignity of two residents with indwelling urinary catheters by allowing their catheter drainage bags to remain exposed rather than covered with a privacy or dignity bag. Resident 35 was cognitively intact and had an indwelling urinary catheter documented in the MDS, care plan, and physician orders. During observations, the resident was seen sitting in a wheelchair with the catheter drainage bag attached to the underside or side of the chair and visible from the hallway, and later exposed while returning from the activity room with other residents. Resident 52 was also cognitively intact and had an indwelling urinary catheter documented in the MDS, care plan, and physician orders. During observation, she was sitting in the hall with other residents and her catheter drainage bag was hanging from her chair and exposed to others without a privacy bag. A nurse aide, an LPN, and the DON confirmed that both residents' catheter drainage bags were exposed and should have had dignity or privacy covers.
Missing Floor Tiles and Unsanitary Shower Areas
Penalty
Summary
The facility failed to provide a clean and homelike environment in one resident’s room and in the second floor shower room. Resident 13’s admission MDS dated January 5, 2026, showed the resident was cognitively intact and ambulated with a wheeled walker. During observation on March 2, 2026, a large floor tile was missing in front of the resident’s chair in the room. During observation on March 3, 2026, several tiles were missing from the shower floor around the drain in the second floor shower room, and the missing-tile areas contained a slimy black removable substance. The Maintenance Director stated on March 5, 2026, that the missing floor tiles should be replaced in the resident’s room and shower room and that the shower should be sanitized.
Failure to Investigate Resident Food Grievances
Penalty
Summary
The facility failed to ensure that a thorough investigation was completed into residents’ concerns raised during food committee meetings regarding the menu. A facility policy dated July 10, 2025 stated that concerns and grievances received by Social Services or designee would be investigated within 72 hours and the complainant informed within seven days. However, food committee meeting minutes dated December 17, 2025 and January 21, 2026 documented that residents wanted anything other than chicken and were tired of chicken and sweet potatoes, with no documented evidence that these concerns were addressed. The current menu cycle showed chicken being served 15 times over 21 days, including lunch every Monday, Tuesday, and Friday and dinner every Wednesday and Saturday. The Dietary Director stated he was not aware of any concerns with the food and said the former administrator had previously communicated with him. The Activity Director confirmed residents said there was a lot of chicken on the menu but did not complete a grievance form, and she also stated the Dietary Director had not attended food committee meetings in the past five months. The Nursing Home Administrator confirmed the dietary concerns should have been documented on a form, given to dietary, and escalated if there was no response.
Improper use of broda chair wheel locks as a restraint
Penalty
Summary
The facility failed to ensure that a resident was free from a physical restraint not required for medical treatment. Resident 48 had a quarterly MDS assessment dated February 4, 2026 showing severe cognitive impairment, dependence on staff for daily care needs, and diagnoses of osteoarthritis of the knee and intellectual disabilities. The facility’s restraint policy, dated July 10, 2025, defined restraints as any manual, physical, or mechanical device, material, or equipment that restricts a resident’s freedom of movement or access to their body. On March 2, 2026, Resident 48 was observed seated in a broda chair in the second floor dining room with the locks on the back two wheels engaged. The resident was trying to push the chair away from the table, and a wooden puzzle was thrown to the floor. A visitor picked it up and returned it. When an LPN later entered the dining room, she unlocked both wheel brakes. During the observation, the LPN stated the brakes were on to keep the resident from rolling backwards because the building was old and uneven, and confirmed that both locks were engaged and prevented the resident from moving. On March 5, 2026, Resident 48 was again observed in the dining room, and when a staff member assisted another resident to a table, Resident 48 used her hands to push away from the table and self-propelled along the table. The Regional Consultant/Acting DON stated she was unable to find documentation showing the resident’s broda chair had been locked.
Failure to Assess and Plan for PTSD Triggers
Penalty
Summary
The facility failed to ensure that Resident 11, who had diagnoses including depression, anxiety, and PTSD, was assessed for trauma-informed care needs and received care to eliminate or minimize triggers. The admission MDS dated November 20, 2025, showed the resident was cognitively impaired and dependent on staff for daily care needs. The clinical record contained no documented evidence that the facility identified the resident’s specific PTSD triggers, implemented measures to prevent or reduce triggers, or developed a care plan for PTSD. During interview on March 5, 2026, the Acting DON and Regional Consultant stated she believed the resident did not trigger for PTSD because the family said they did not believe he had it, and therefore the facility did not assess for triggers or create a PTSD care plan.
Annual Nurse Aide Performance Evaluations Not Completed
Penalty
Summary
The facility failed to ensure that nurse aide performance evaluations were completed at least annually for three of five nurse aides reviewed: Nurse Aide 4, Nurse Aide 5, and Nurse Aide 6. Review of personnel files showed that Nurse Aide 4, hired July 14, 2010, had no evidence of a performance evaluation completed since July 2024; Nurse Aide 5, hired June 1, 2017, had no evidence of a performance evaluation completed since July 2024; and Nurse Aide 6, hired June 14, 2011, had no evidence of a performance evaluation completed since August 2024. The Nursing Home Administrator confirmed in interview on March 4, 2026, that these performance evaluations had not been completed since 2024 and stated that they should be done annually.
Improper Dating and Disposal of Insulin and Diabetes Medications
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in accordance with facility policy and manufacturer instructions. During observation of the second floor medication cart, a Novolog KwikPen for Resident 80 was found opened on a date that made it past the 28-day discard timeframe, and the LPN confirmed it was expired and should have been discarded. On the first floor long hall medication cart, an Ozempic pen for Resident 82 and a Lantus pen for Resident 72 were both opened with no date documented, and a Basaglar pen for Resident 46 was opened on a date that placed it beyond the 28-day discard period. The LPN and DON confirmed the missing dates and expired medication issues during interview. The residents involved had diagnoses including diabetes mellitus type 2, and several had additional conditions and care needs. Resident 80 was cognitively intact, used a walker and/or wheelchair, required assistance for care, and had diabetes mellitus type 2 and heart failure; physician orders included Novolog insulin with meals. Resident 82 was cognitively intact, used a wheelchair or walker, required assistance for care, and had diabetes mellitus type 2; physician orders included Ozempic weekly. Resident 72 was severely cognitively impaired, used a walker or wheelchair, required assistance for care, and had diabetes mellitus type 2 and dementia; physician orders included daily Lantus. Resident 46 was severely cognitively impaired, used a walker or wheelchair, required assistance for care, and had diabetes mellitus type 2 and stroke with right-sided weakness; physician orders included daily Basaglar.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to honor a resident’s food preference when Resident 26, who was cognitively intact, required assistance with care, and was independent with eating after set-up, received broccoli on her lunch tray even though her dietary management food preferences sheet and meal ticket both indicated that she disliked broccoli. Her nutritional care plan also identified her as being at risk for significant weight loss related to recent inadequate intakes and frequent meal refusals, and included an intervention to provide favorite foods within diet. During observation of the lunch meal, Resident 26 stated that she did not like broccoli after seeing it on her tray. The facility’s nutrition services policy stated that patient preferences are to be taken into consideration when menu selections are placed and that appropriate dietary substitutions are to be made. The Dietary Director confirmed in interview that Resident 26 should have been provided another vegetable option and should not have received broccoli on her meal tray.
QAPI Committee Failed to Correct Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct repeated quality deficiencies identified across multiple surveys and complaint investigations. The report states that prior plans of correction for surveys ending April 10, 2025, August 19, 2025, and February 10, 2026 included quality assurance systems intended to keep the facility in compliance with cited nursing home regulations, but the current survey ending March 5, 2026 found repeated deficiencies related to quality of care, food storage/prepare/serve-sanitary, and infection control. For the quality of care deficiency cited under F684, the facility’s prior plans of correction said audits would be completed and results reported to the QAPI committee for review, but the current survey found that the QAPI committee failed to successfully implement the plan to ensure quality care was provided. For the food storage/prepare/serve-sanitary deficiency cited under F812, the same type of audit-and-report plan was previously listed, but the current survey found the QAPI committee failed to successfully implement the plan to ensure food was stored, prepared, and served sanitarily. For the infection control deficiency cited under F880, the prior plan of correction from the April 10, 2025 survey also called for audits and reporting to QAPI, but the current survey found the committee failed to successfully implement the plan regarding infection control.
Missing Infection Control Signage for Residents with Foley Catheters
Penalty
Summary
The facility failed to ensure that appropriate infection control signage was posted for three residents with indwelling urinary catheters. The facility policy dated July 10, 2025 stated that isolation precautions were to be implemented when a resident had an indwelling catheter and that the appropriate isolation sign was to be posted on the room entrance door. Resident 35, Resident 89, and Resident 90 each had admission MDS assessments showing an indwelling urinary catheter, care plans identifying a Foley catheter, and physician orders for a urinary catheter. Observations on March 2 and March 3, 2026 showed the residents in their rooms with no enhanced barrier precaution signs posted at the entrances. An LPN confirmed there was no signage on the doors for these residents, and the Infection Control Nurse also confirmed that infection control signs should have been posted by their rooms.
Failure to Honor Resident Representative’s Request for Hospital Evaluation
Penalty
Summary
The facility failed to honor a resident and responsible party's right to make informed decisions regarding treatment when a request for hospital evaluation was not followed. Facility policy on residents' rights and advanced directives stated that residents have the right to request, refuse, and/or discontinue medical or surgical treatment. The resident involved was cognitively impaired, required staff assistance for daily care, had cirrhosis of the liver, was receiving hospice services, and had a PleurX catheter with a care plan directing nursing staff to monitor the dressing and observe for signs of infection or worsening condition. A nurse's note documented that the resident's wife, acting as responsible party, requested that the resident be sent to the emergency room due to continued leaking from the liver catheter and asked to speak with the provider. The nurse contacted the CRNP with an assessment, and the CRNP consulted with the hospice nurse. They agreed the resident did not need to go to the emergency room and that the hospice nurse could assess the resident at the facility. When informed of this, the resident's wife insisted on taking her husband to the emergency room and verbally rejected hospice and the facility's position. Staff told her she had the right to go to the emergency room but could not provide an order for transfer and that leaving would be against medical advice because the provider wanted the resident to remain for hospice assessment. An interview with the Regional RN confirmed that if the responsible party requested hospital evaluation, the resident should have been sent, indicating that the facility did not honor the responsible party's request for transfer for evaluation.
Failure to Follow Antibiotic Orders and Inadequate Wound Assessment
Penalty
Summary
Surveyors identified that one resident did not receive antibiotic therapy as ordered and another resident did not receive appropriate wound assessment. For the first resident, the admission MDS showed cognitive impairment, dependence on staff for daily care, cirrhosis of the liver, and enrollment in Hospice services. Physician orders dated early January directed that 500 mg of Cipro be administered every morning and at bedtime for 10 days to treat purulent drainage. Review of the MAR showed that the first two scheduled doses of Cipro were documented as not administered, and the medication was then given twice daily from the evening of the following day through the morning of the tenth day, resulting in only nine days of therapy. The Regional RN confirmed that the Cipro order should have been adjusted when the first two doses were missed so that the resident would still receive the antibiotic for the full 10 days as ordered, but this was not done. For the second resident, the admission MDS indicated that the resident was cognitively intact, occasionally bowel incontinent, and had no wounds. A care plan required weekly skin assessments and direction for the charge nurse to notify the wound nurse, physician, and family of any new skin areas. An initial skin assessment documented intact skin, and physician orders were obtained for zinc oxide to be applied to both buttocks and the coccyx every shift for prevention. A subsequent skin assessment documented that the resident’s skin was no longer intact, with treatment in place to the buttocks and coccyx, but there was no documented assessment of the change from intact to not intact skin and no evidence that the wound nurse was notified. A later skin assessment described a closed abrasion on the right buttock and blanchable redness on both buttocks, and the Regional RN confirmed there was no assessment of the area at the time the skin first changed.
Failure to Follow Updated Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to provide pressure ulcer treatment according to current physician and CRNP orders for one resident with a right heel pressure ulcer. A quarterly MDS for this resident showed confusion, extensive assistance needs for daily care, and the presence of pressure ulcers. A CRNP wound nurse note documented that the treatment for the right heel pressure ulcer was changed from Gentamicin to Calmoseptine on February 3, 2026, and a physician’s order dated February 4, 2026, specified cleansing the right foot with soap and water, applying Calmoseptine, then a heel cup, with daily dressing changes. However, review of the February 2026 TAR showed that as of February 10, staff continued to apply Gentamicin ointment to the right heel pressure ulcer in the evenings while also applying Calmoseptine in the mornings, resulting in both ointments being used instead of only Calmoseptine as ordered. In an interview, the Regional Nurse confirmed that Gentamicin should have been discontinued when the treatment was changed, but it was not, and staff continued to apply both treatments.
Improper Storage of Portable Oxygen Tank on Hallway Stretcher
Penalty
Summary
Surveyors identified a deficiency related to accident hazards when a portable oxygen tank was found improperly stored on a metal stretcher in the 100 hall, short side. The facility’s oxygen policy dated December 10, 2025, required that portable oxygen tanks be stored safely in an upright position. However, during observation on February 10, 2026 at 1:45 p.m., a full portable oxygen tank was seen lying unsecured on the middle section of a metal stretcher parked in the hallway outside residents’ rooms and within residents’ reach. An interview with an LPN at the time of the observation confirmed that the oxygen tank should not have been stored on the stretcher in the hallway and that she did not know why the stretcher was there. In a subsequent interview, the Regional Nurse also confirmed that the oxygen tank should have been stored securely and not lying on a stretcher in the hallway, indicating the facility failed to maintain an environment free from accident hazards as required by policy and regulation. No specific resident medical histories or conditions were described in relation to this deficiency, only that the unsecured oxygen tank and stretcher were located within reach of residents’ rooms on the 100 hall.
Failure to Administer Medication per Physician's Orders
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders regarding medication administration for one resident. The facility's policy required that medications be administered by licensed nurses as ordered by the physician. The resident, who was cognitively intact and had a diagnosis of heart failure, had a physician's order to receive 50 mg of Metoprolol Succinate daily for hypertension. On March 6, 2025, the physician reviewed the resident's medications and ordered the Metoprolol dose to be decreased to 25 mg daily. However, the new order for 25 mg of Metoprolol was not added to the Medication Administration Record (MAR), resulting in the resident not receiving any Metoprolol Succinate from March 7, 2025, to July 28, 2025. This lapse was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the medication order change was not implemented and the resident did not receive the prescribed medication during this period.
Failure to Provide and Document Pressure Ulcer Treatment as Ordered
Penalty
Summary
A review of facility policies, clinical records, and staff interviews revealed that the facility failed to provide pressure ulcer treatments as ordered by the physician for one resident. The facility's wound management policy required that wound treatments be administered according to physician orders, specifying the cleansing method, dressing type, and frequency. The resident in question was cognitively impaired, incontinent of bowel and bladder, and at risk for pressure ulcers. On assessment, the resident was found to have a fluid-filled blister on the right abdomen, with physician orders directing the application of a protective barrier every day and evening shift. The care plan also specified avoidance of tight clothing and adherence to the treatment orders. However, review of the Treatment Administration Records for the relevant month showed no documented evidence that the prescribed treatments were completed as ordered. This lack of documentation was confirmed by the Nursing Home Administrator.
Failure to Follow Physician Orders and Manufacturer Instructions for Medication and Wound Care
Penalty
Summary
The facility failed to follow physician's orders and manufacturer instructions for medication administration, as well as wound care recommendations, for three residents. One resident, who was cognitively intact and had diabetes, received Humalog insulin on multiple occasions despite blood sugar readings below the threshold specified in the physician's order, which required the insulin to be held if blood sugar was less than 100 mg/dL. Another resident, also cognitively intact and with diabetes, received Humalog insulin at times not aligned with the manufacturer's instructions, which state the medication should be administered within 15 minutes before or immediately after meals. The insulin was given at times that did not correspond with scheduled meal times. Additionally, a resident with cognitive impairment and frostbite wounds to the toes did not receive wound care as recommended by a wound consultant. The consultant recommended betadine be applied to the first and second toes of both feet twice daily, but physician's orders only included the right foot, and there was no documentation that the left toes received the recommended treatment. These deficiencies were confirmed through review of clinical records, medication and treatment administration records, and interviews with facility leadership.
Failure to Follow Wound Care Treatment Orders for Pressure Ulcer
Penalty
Summary
The facility failed to follow wound care treatment recommendations for a resident with a Stage 3 pressure ulcer on the coccyx. According to the facility's wound treatment policy, evidence-based treatments should be provided in accordance with physician orders. The resident, who was cognitively impaired and required assistance with care, had wound consultations that recommended daily application of collagen to the wound bed and zinc to the peri-wound area. However, review of the Treatment Administration Records showed that collagen was not applied daily as ordered from January 15 through February 5. Further, a subsequent wound consultation recommended daily application of bacitracin ointment and collagen to the wound bed, but records indicated that no treatment was applied to the coccyx from February 20 through 26. The DON confirmed that the recommended treatments were not completed as ordered on the specified dates.
Deficiencies in Food Storage, Staff Attire, and Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service as outlined in its own policies. During observations, multiple food items in the walk-in cooler and freezer were found either not labeled with preparation or opening dates or not properly secured, including trays of chicken and broccoli, as well as opened bags of vegetables and dinner rolls. Additionally, scoops for flour and rice were stored inside their respective bins, contrary to policy. The Dietary Manager confirmed that these practices did not comply with facility protocols. Further deficiencies were observed in staff compliance with uniform dress code and cleanliness of food service areas. Several dietary workers were seen with hair not fully covered by hair nets while handling and preparing food. Non-food contact surfaces, such as a blower fan and shelving unit used for storing pans and cookie sheets, were found to be coated with dust and debris. The Dietary Manager acknowledged that these conditions did not meet the facility's standards for cleanliness and staff attire.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that staff reported an allegation of verbal abuse in a timely manner. According to the facility's abuse policy, staff are required to immediately report any suspected abuse to administration. In this incident, a nurse aide overheard another nurse aide yelling at a cognitively impaired resident who required assistance with daily care and had a diagnosis of hydrocephalous. The nurse aide told the resident that she did not deserve her shoes due to her behavior while getting ready. Despite witnessing this, the staff member did not immediately report the incident to administration, resulting in a delay of several days before the allegation was brought to the attention of facility management.
Failure to Obtain Ordered Laboratory Test for Anticoagulation Monitoring
Penalty
Summary
The facility failed to obtain a laboratory test as ordered by the physician for one resident who was receiving anticoagulation therapy. According to facility policy, the charge nurse is responsible for obtaining physician orders for pertinent labs and notifying the physician of results, specifically for residents on medications such as warfarin. The resident in question had a history of atrial fibrillation and cerebral infarction, was cognitively impaired, and required assistance with care needs. After a critically high PT/INR result, the resident's anticoagulation therapy was adjusted, and a repeat PT/INR was ordered and completed the following day. Subsequently, the physician ordered another INR blood test to be performed on a specific date. However, there was no documented evidence that this laboratory test was completed as ordered. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the test was not performed as required by the physician's order.
Failure to Implement Enhanced Barrier Precautions for High-Risk Resident
Penalty
Summary
The facility failed to follow established infection control guidelines from CMS and CDC regarding Enhanced Barrier Precautions (EBP) for a resident with significant risk factors for multidrug-resistant organism (MDRO) transmission. Specifically, a resident who was admitted with an indwelling urinary catheter, a Stage 4 pressure ulcer, and a wound infection did not have EBP implemented upon admission, despite facility policy and federal guidance requiring gown and glove use during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of known MDRO status. Documentation showed that EBP was not initiated until after the resident was removed from contact precautions for an MDRO, and there was no evidence of an EBP order or care plan addressing these precautions at the time of admission. Interviews with the Assistant Director of Nursing/Infection Preventionist and the Director of Nursing confirmed that EBP was not documented or ordered when the resident was admitted, and the care plan was only updated after contact precautions were discontinued. The lack of timely implementation and documentation of EBP for this high-risk resident constituted a failure to adhere to both facility policy and current infection control standards, as required by regulatory guidelines.
Failure to Submit Direct Care Staffing Information
Penalty
Summary
The facility failed to electronically submit direct care staffing information for the first quarter of the fiscal year 2024, as required by Section 6106 of the Affordable Care Act (ACA). This requirement mandates that facilities submit staffing data, including agency and contract staff, based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS) by the end of the 45th calendar day after the last day of each fiscal quarter. For the first quarter, covering October 1st through December 31st, the submission was due by February 14th. A review of the Payroll Based Journal (PBJ) staffing data reports revealed that the facility did not submit the required data for this period. This deficiency was confirmed during an interview with the Nursing Home Administrator on May 21, 2024.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect changes in residents' care needs for three residents. For Resident 28, the care plan was not updated to reflect the discontinuation of a midline and antibiotic therapy, despite a nursing note indicating these changes. The Nursing Home Administrator confirmed that the care plan should have been resolved but was not. Similarly, Resident 39's care plan was not updated to reflect the discontinuation of contact isolation precautions and completion of antibiotic therapy, as noted in a nursing note. The care plan still indicated isolation/quarantine precautions for MRSA and VRE, which should have been resolved. Additionally, Resident 75's care plan did not include the need for a wound vac to the right knee, despite physician's orders and a nursing note indicating this requirement. The Nursing Home Administrator confirmed that the care plan was not updated accordingly.
Failure to Follow IV Line Care Protocols
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration and maintenance of intravenous (IV) lines for a resident. Specifically, the facility did not flush the resident's midline catheter with saline before and after administering levofloxacin, an antibiotic, on several occasions. The resident, who was cognitively intact, was receiving IV medications for a Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Despite physician orders to flush the central line with 5-10 mL of saline before and after medication administration and to perform a maintenance flush every shift, there was no documented evidence of these actions being completed on specified dates. Additionally, the facility did not change the resident's intravenous line dressing and caps as ordered by the physician. The Medication Administration Record (MAR) lacked documentation of the required dressing and cap changes on specific dates. An interview with the Nursing Home Administrator confirmed the absence of documentation for these essential care tasks, indicating a failure to comply with the facility's policy and physician orders for IV catheter care.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions for ice preparation and storage, as well as proper food storage in the main kitchen. Observations revealed a dark, removable substance inside the second-floor ice machine, indicating it had not been cleaned as per the facility's policy, which requires monthly cleaning with an approved sanitizing agent. The Assistant Maintenance Director confirmed that the second-floor ice machine was overdue for cleaning, and there was no documented evidence of it being cleaned for the month of May. Additionally, the facility did not adhere to professional standards for food storage. In the main kitchen's walk-in refrigerator, a large brick of cheese was found unsealed and exposed to air, and a large container of brown rice was observed with an expiration date of February 2022. The Dietary Manager confirmed that the cheese should have been sealed and the expired rice discarded, indicating a failure to follow the facility's policy for food storage based on Hazard Analysis Critical Control Point (HACCP) guidelines.
Failure to Maintain Resident's Personal Grooming and Hygiene
Penalty
Summary
The facility failed to provide appropriate personal grooming and hygiene services for a resident who was dependent on care. The facility's policy, dated April 16, 2024, required that nail care, including cleaning and trimming, should be completed as needed unless contraindicated by conditions such as diabetes, in which case a nurse or podiatrist would provide care. A quarterly Minimum Data Set (MDS) assessment for the resident, dated February 19, 2024, indicated that the resident had Alzheimer's and dementia, and required extensive assistance with activities of daily living, including bathing. Observations on multiple occasions in May 2024 revealed that the resident's fingernails extended beyond the tips of her fingers and had a dark substance underneath them. The resident was scheduled to receive showers twice a week, with the last recorded shower on May 17, 2024. An interview with a nurse aide confirmed that the resident's fingernails were not cleaned as required, either during her scheduled showers or at any other time when staff noticed the need for such care. This failure to maintain the resident's personal grooming and hygiene was a deficiency in the facility's nursing services.
Failure to Ensure Functioning Safety Interventions
Penalty
Summary
The facility failed to ensure that interventions were in place and functioning to prevent inappropriate behaviors for a resident. The resident, who was cognitively intact but displayed sexually inappropriate behavior, was involved in an incident where he touched another resident inappropriately in the hallway. Following this incident, the resident's care plan was revised to include a motion alarm on his door frame and a requirement for supervision when out of his room. However, observations revealed that the motion alarm on the resident's door was not functioning properly. A Licensed Practical Nurse confirmed that the alarm was in the off position and should have been on. Despite attempts to fix it, the alarm continued to malfunction. The Nursing Home Administrator confirmed that there was no documented evidence of the alarm being monitored for function and placement, indicating a failure in ensuring the safety measures were operational.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents, leading to a deficiency in pharmaceutical services. For one resident, an admission MDS assessment indicated the resident had an unstageable pressure ulcer and required assistance with care needs. A physician's order was in place for the resident to receive oxycodone for pain management. However, the controlled drug accountability records showed that doses of oxycodone were signed out for administration on specific dates, but there was no documented evidence in the MAR that the medication was administered to the resident at those times. This discrepancy was confirmed by the Nursing Home Administrator. Similarly, another resident, who was alert and oriented and received as-needed pain medications, had physician's orders for oxycodone to be administered for pain relief. The controlled drug accountability records indicated that doses were signed out on several occasions, but again, there was no documented evidence in the MAR that the medication was administered. This lack of documentation was also confirmed by the Nursing Home Administrator. These findings indicate a failure to adhere to the facility's policy on medication administration and accountability for controlled substances.
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. The deficiencies were related to care plan timing and revision, grooming and personal and oral hygiene, and ensuring that the resident's environment remained free from accident hazards. Despite having developed plans of correction following previous surveys, the facility continued to exhibit the same issues, indicating that the QAPI committee's efforts were insufficient in maintaining compliance with nursing home regulations. Specifically, the facility had previously developed plans of correction that included conducting audits and reporting the results to the QAPI committee. However, the current survey revealed that these plans were not successfully implemented. The deficiencies cited under F657, F677, and F689 showed that the QAPI committee was ineffective in ensuring ongoing compliance with regulations regarding updating residents' care plans, maintaining grooming and personal and oral hygiene, and keeping the resident environment free from accident hazards.
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.
Illustrative
What surveyors actually found near you
We read the 209 citations issued within 25 miles in the last 12 months — 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 Huntingdon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Woods At Huntingdo | 1.5 mi | ★★★★★ | 7 | 0 |
| Cedarwood Rehabilitation & Healthcare Center | 17.1 mi | ★★★★★ | 17 | 0 |
| Valley View Haven, Inc | 18.2 mi | ★★★★★ | 5 | 0 |
| Embassy Of Woodland Park | 18.8 mi | ★★★★★ | 15 | 0 |
| Maybrook Hills Rehabilitation And Healthcare Cente | 19.2 mi | ★★★★★ | 3 | 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.