The finding was not a surprise to anyone who has followed the facility's inspection history.
Nursing Home News — Page 129
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The facility submitted a plan of correction, the standard response nursing homes provide when inspectors find problems.
On paper, it was a reasonable system.
The facility responded with a plan of correction, the standard mechanism by which nursing homes acknowledge a problem and commit, in writing, to solving it.
The first citation came during a survey ending April 25, 2024.
The inspection resulted in a citation under F842, the federal tag that covers clinical records.
That is the core finding from a March 2025 inspection of Embassy of Hillsdale Park in Hillsdale, Pennsylvania.
Federal inspectors who arrived at Addolorata Villa on January 16 found the facility wasn't following it.
Two surveyors documented the skin tear on March 31, 2025, at 11:22 in the morning.
It is not a paperwork violation.
The citation, issued under F689, covers the requirement that a nursing home identify and remove hazards that put residents at risk of accidents.
Nearly a year had passed since the facility signed its name to a corrective action.