Embassy of Huntingdon Park: Medication Order Failures - PA
The medication error occurred despite the physician visiting the facility in person to review the resident's medications and specifically ordering the dosage reduction.
Resident 2, who was cognitively intact and required assistance with personal care, had been receiving 50 milligrams of Metoprolol Succinate daily for high blood pressure since October 31, 2024. The medication treats hypertension in patients with heart conditions.
On March 6, 2025, the resident's physician visited the facility and reviewed all medications. The doctor ordered a reduction in the Metoprolol dose from 50 mg to 25 mg daily, according to nursing notes from that date.
But the new order was never added to the facility's Medication Administration Record.
From March 7 through July 28, 2025, the resident received no Metoprolol Succinate at all. The original 50 mg order had been discontinued, but the replacement 25 mg order never made it onto the medication chart that nurses use to track daily drug administration.
The gap lasted 143 days.
Federal inspectors discovered the error during an August 19 complaint investigation. They found that physician orders dated July 28, 2025, included a new order for the resident to receive 25 mg of Metoprolol Succinate daily for hypertension.
The facility's own medication administration policy, dated July 10, 2025, states that medications must be given by licensed nurses "as ordered by the physician and in accordance with professional standards of practice."
When inspectors interviewed the nursing home administrator at 9:46 p.m. on August 19, the administrator confirmed the sequence of events. The administrator acknowledged that Resident 2's Metoprolol order had been decreased to 25 mg daily on March 6, 2025, but admitted the new order was never added to the medication record.
The administrator also confirmed the resident had not received any Metoprolol Succinate between March 7 and July 28, 2025.
Metoprolol Succinate is a beta-blocker commonly prescribed for patients with heart failure and high blood pressure. The medication helps reduce the workload on the heart and lower blood pressure by blocking certain nerve impulses.
For a resident with documented heart failure, missing this medication for nearly five months could have serious cardiovascular consequences. The drug is typically prescribed as a long-term treatment to prevent complications from heart conditions.
The inspection report notes that the facility policy requires medications to be administered by licensed nurses or other legally authorized staff according to physician orders. The policy emphasizes following professional standards of practice.
Federal inspectors reviewed seven residents' medication records during the investigation. Only Resident 2 experienced this type of medication administration failure.
The error appears to stem from a breakdown in the facility's process for updating medication orders. While the physician's March 6 visit was documented in nursing notes, the dosage change never translated into updated instructions for the nursing staff responsible for daily medication administration.
The facility uses a Medication Administration Record system to track which medications each resident should receive and when. This record serves as the primary reference for nurses during medication rounds.
When the doctor reduced the Metoprolol dose, staff discontinued the old 50 mg order but failed to create a new entry for the 25 mg dose. This left the resident without any order for the blood pressure medication in the system.
The problem went undetected for months, suggesting gaps in the facility's medication monitoring and physician order verification processes.
Federal regulations require nursing homes to ensure residents receive treatment and care according to physician orders and their individual care needs. The regulation cited in this case specifically addresses providing appropriate treatment according to orders and resident preferences.
Inspectors classified this as a violation with minimal harm or potential for actual harm. However, for Resident 2, the nearly five-month gap in prescribed heart medication represented a significant lapse in medical care.
The error was only corrected when new physician orders were written on July 28, 2025, nearly five months after the original dosage change. The resident finally began receiving the prescribed 25 mg daily dose of Metoprolol Succinate.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Embassy of Huntingdon Park from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
EMBASSY OF HUNTINGDON PARK in HUNTINGDON, PA was cited for violations during a health inspection on August 19, 2025.
The medication treats hypertension in patients with heart conditions.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.