The inspection resulted in a citation under F842, the federal tag that covers clinical records.
Nursing Home News — Page 479
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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.
Chronic wounds and indwelling catheters are not minor clinical concerns.
When inspectors asked about it, the Social Services Director was direct about why: she does not do resident visits in the room.
Inspectors cited the facility under F689, the federal tag that covers accident hazards and supervision, noting that a few residents were affected.
The jeopardy, inspectors determined, had actually begun six days earlier, on February 26.
The violations ranged from missing paperwork before emergencies to a resident left without an intervention to prevent a skin tear.