Embassy of Huntingdon Park: Medication Order Ignored - PA
The resident, identified in inspection records only as Resident 2, had been prescribed 50 milligrams of Metoprolol Succinate daily since at least October 2024 to treat hypertension. Metoprolol is a beta-blocker commonly used to manage high blood pressure and reduce strain on the heart, a particular concern for someone already living with heart failure. The resident was cognitively intact and required assistance with personal care, according to a June 2025 assessment of his abilities and care needs.
On March 6, 2025, a physician came into the facility, reviewed the resident's medications at the bedside, and gave a verbal order to cut the Metoprolol dose in half, from 50 milligrams to 25 milligrams daily. A nurse documented the visit and the new order in a progress note that same day.
Nobody updated the medication administration record.
The medication administration record is the document nurses consult each time they dispense a drug. Without the new order entered there, staff kept giving the resident the old dose, or in this case, nothing at all. The inspection found that Resident 2 received no Metoprolol Succinate between March 7 and July 28, 2025, a span of 143 days. The physician's order reducing the dose to 25 milligrams wasn't formally re-entered into the system until July 28, more than four months after the doctor had already made the change in person.
The nursing home administrator confirmed the sequence of events during an interview with inspectors on the evening of August 19, 2025. The administrator acknowledged that the March 6 order was never added to the medication administration record and that the resident received no Metoprolol during the entire period between March 7 and July 28.
What the inspection record does not explain is how a gap of nearly five months went unnoticed. A physician had been in the building, reviewed the chart, and issued an order. A nurse had written it down in a progress note. Yet no one caught that the change had never made it to the document nurses actually use when dispensing medications, and no one appears to have flagged that a resident with heart failure and high blood pressure had quietly stopped receiving a cardiac drug.
The facility's own medication policy, updated as recently as July 10, 2025, states that medications are to be administered as ordered by the physician and in accordance with professional standards of practice. That policy was in place for the final three weeks of the gap. It did not close it.
Inspectors rated the violation as causing minimal harm or the potential for actual harm, the lower end of the federal harm scale. The citation was issued under Pennsylvania nursing services regulations.
Resident 2 was cognitively intact throughout this period. He could, in principle, have asked why his pill looked different or why he wasn't receiving it. Whether he did, and what anyone said to him if he did, the inspection record does not say.
What it does say is that a man with a failing heart spent the better part of five months without a medication his doctor had ordered, because one line was never typed into a form.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
EMBASSY OF HUNTINGDON PARK in HUNTINGDON, PA was cited for violations during a health inspection on August 19, 2025.
The resident was cognitively intact and required assistance with personal care, according to a June 2025 assessment of his abilities and care needs.
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.