Embassy Of Hillsdale Park

bed-hold policies.

failed to notify the resident and/or the resident's representative, in writing regarding the reason for

33 residents reviewed (Resident 5).Findings include:A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 16, 2026, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs and had diagnoses that included dementia.A nursing note for Resident 5, dated September 7, 2025, revealed that at 1:25 p.m. the resident had a witnessed fall in the hallway resulting in a skin tear to her left ring finger and a reddened area on the left side of her forehead.

She was transferred to the hospital and admitted with altered mental status, a head injury, and seizures.Review of Resident 5's clinical record revealed that there was no documented evidence that the resident and legal guardian were notified in writing of the purpose for the resident's transfer, or that the ombudsman was notified regarding her hospitalization of September 7, 2025.Interview with the Nursing Home Administrator on February 20, 2026, at 10:46 a.m. confirmed that there was no documented evidence that Resident 5 and their representative were notified in writing of their transfer to the hospital, or that the ombudsman was notified regarding the hospitalizations.28 Pa.

Code 201.29(j) Resident Rights.

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Embassy of Hillsdale Park 383 Mountain View Drive Hillsdale, PA 15746

actions that can be measured.

the facility failed to develop and implement an individualized care plan for one of 33 residents

indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents medical, nursing, and mental and psychosocial needs. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated January 2, 2026, revealed that the resident was cognitively intact, was understood, could understand, and required supervision with care needs.Interview with Resident 9 on February 17, 2026, at 10:42 revealed that she has been having diarrhea for a while, and still has to take medication. A nursing note for Resident 9 dated January 28, 2026, indicated that she had a colonoscopy.Physician's orders for Resident 9, dated October 21, 2025, included an order for the resident to receive 2.5-0.025 milligrams (mg) of Lamotil (an antidiarrheal medication) every six hours as needed for for diarrhea.

Physician's orders for Resident 9, dated January 28, 2026, included an order for the resident to receive 2.4 grams (gm) of Mesalamine (an anti-inflammatory medication) twice a day for ulcerative colitis (chronic inflammatory bowel disease).There was no documented evidence that a care plan was developed to address Resident 9's chronic diarrhea and ulcerative colitis.Interview with the Nursing Home Administer on February 19, 2026, at 12:13 p.m. confirmed that Resident 9 did not have a care plan to address her chronic diarrhea and ulcerative colitis with medications.28 Pa.

Code 211.11(d) Resident care plan.28 Pa.

Code 211.12(d)(5) Nursing services.

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Embassy of Hillsdale Park 383 Mountain View Drive Hillsdale, PA 15746

of practice, by failing to ensure that physician's orders were followed for one of 33 residents

mandated assessment of a resident's abilities and care needs) for Resident 68, dated December 20, 2025, revealed that the resident was understood and could understand others, was cognitively intact, and had diagnoses that included hypertension (high blood pressure), and heart failure. A care plan, dated June 14, 2024, revealed that staff were to give all cardiac medications as ordered by the physician.Physician's orders for Resident 68, dated July 15, 2025, included an order for the resident to receive 12.5 milligrams (mg) of Coreg (used to treat high blood pressure) two times a day for hypertension.

Staff was to hold the medication for a blood pressure reading of less than 90/60 millimeters of mercury (mmHg) or a heart rate less than 60 beats per minute (bpm).Review of Resident 68's Medication Administration Record (MAR) for October and November 2025, and February 2026, revealed that the resident's pulse was less than 60 bpm at 7:00 a.m. on October 1, 4, 5, 9, 14, 15, 22-24, and 27-29, November 1, 2, 5-7, 10-12, 16, 19-21, 25-27, 29, and 30, 2025, and February 3, 4, 7, 8, 11-13, 16-18, 2026; however, there was no documented evidence that Coreg was held as ordered by the physician.Interview with the nursing Home Administrator on February 19, 2026, at 11:32 a.m. confirmed that there was no documented evidence that Resident 68's Coreg was held as ordered on the above dates and times.28 Pa.

Code 211.12(d)(1)(5) Nursing Services.

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Embassy of Hillsdale Park 383 Mountain View Drive Hillsdale, PA 15746

Observation made in the bathroom sink in room [ROOM NUMBER] on February 19, 2026, at 12:45 p.m. revealed that the water felt hot to the touch and the temperature was 120.3 degrees F.

Interview with Licensed Practical Nurse 1 at the time of this observation revealed that the water was hot to touch and that she was unaware of any reported concerns by residents, staff, or visitors that the water was too hot.

Observations of the Maintenance Director checking water temperatures in the shared bathroom sink between rooms [ROOM NUMBERS] on February 19, 2026, at 12:54 p.m. revealed a temperature of 115 degrees F.Observations of the Maintenance Director checking water temperatures in the bathroom sink in the shared hallway bathroom across from room [ROOM NUMBER] on February 19, 2026, at 12:56 p.m. revealed a temperature of 131 degrees F. An interview with the Maintenance Director at the time of these observations confirmed that the water temperature was too hot and should be between 100 and 110 degrees F.

Observations of the Maintenance Director checking water temperatures in the bathroom sink in room [ROOM NUMBER] on February 19, 2026, at 1:13 p.m. revealed a temperature of 121.6 degrees F. An interview with the Maintenance Director at the time of the observation confirmed that the water temperature was too hot.

Interview with the Maintenance Director on February 19, 2026, at 1:50 p.m. revealed that he has not been notified of any concerns by residents, staff, or visitors that the water was too hot, and that he made adjustments to the mixing valves to correct the hot water temperature.

Interview with the Nursing Home Administrator on February 19, 2026, at 2:10 p.m. confirmed that the water temperatures in the residents' room should not have been that high, and that the Maintenance Director had made adjustments to decrease the hot water temperature. 28 Pa.

Code 201.14(a) Responsibility of Licensee.28 Pa.

Code 201.18(b)(1) Management.28 Pa.

Code 211.12(d)(1)(5) Nursing Services.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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Embassy of Hillsdale Park 383 Mountain View Drive Hillsdale, PA 15746

services of a licensed pharmacist.

the facility failed to ensure the accountability of controlled medications (drugs with the potential to be

storage of controlled medications dated April 3, 2025, revealed that the destruction/disposal of controlled medications should include a licensed nurse and a licensed pharmacist or authorized nurse supervisor.

Documentation on the narcotic record will include the name of the resident, medication, prescription number, amount being destroyed, date of disposition and names and signatures of both the persons disposing of the medication.

Physician's orders for Resident 77 dated September 13, 2024, included an order for the resident to receive 0.5 milligrams of Lorazepam (controlled medication for anxiety) one time a day. A nursing note for Resident 77 dated December 23, 2025, revealed that the resident ceased to breath at 4:14 a.m. A controlled narcotic sheet for Resident 77, received on December 1, 2025, revealed that 29 doses of Lorazepam were received. On December 22, 2025, the controlled narcotic sheet revealed that 9 doses of Lorazepam were remaining.

There was no documented evidence that the remaining 9 doses of Lorazepam were destroyed and verified by two licensed nurses.

Interview with the Nursing Home Administrator on February 20, 2026, at 11:35 a.m. confirmed that there was no documented evidence that Resident 77's Lorazepam was destroyed by two licensed nurses per the facility's policy. 28 Pa.

Code 211.9(h) Pharmacy Services. 28 Pa.

Code 211.12(d)(1) Nursing Services.

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Embassy of Hillsdale Park 383 Mountain View Drive Hillsdale, PA 15746

Based on a review of facility policies and clinical records, as well as observations and staff

in a medication cart.

Findings include:The facility's policy regarding medication storage, dated April 3, 2025, revealed that the facility will maintain and control access to medication carts for licensed and approved personnel.

Observations on February 19, 2026, at 2:11 p.m. revealed that Licensed Practical Nurse 2 walked out of the medication room on the ambulatory care unit, leaving the medication cart unlocked and unsupervised inside the medication room and the door to the medication room was held open with a piece of wood.

Interview with Licensed Practical Nurse 2 on February 19, 2026, at 2:14 p.m. confirmed that the medication cart was unlocked and unsupervised inside the medication room and the door to the medication room was held open with a piece of wood, and that both should have been locked. An interview with the Nursing Home Administrator on February 19, 2026, at 2:39 p.m. confirmed that the medication cart should have been locked when unsupervised, and the medication room door should have been closed and locked when the medication room was unsupervised. 28 Pa.

Code 211.12(d)(1) Nursing Services.

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Embassy of Hillsdale Park 383 Mountain View Drive Hillsdale, PA 15746

in accordance with accepted professional standards.

failed to ensure that residents' clinical records were complete and accurately documented for one of

assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 16, 2026, indicated that the resident was cognitively impaired, required assistance from staff for her daily care needs, and had diagnoses that included dementia. A physician's order and care plan for Resident 5, dated September 12, 2025, indicated that the resident was to use a bed and chair alarm per the family's request.Observations of Resident 5 on February 17, 2026, at 10:32 a.m. revealed that the resident was in the hallway in his chair and had an alarm in place.

Review of the Treatment Administration Records (TAR's) and nurse aide documentation for Resident 5, for November and December 2025, and January and February 2026, revealed that there was no documentation by staff that the resident's bed and chair alarms were in place.Interview with the Nursing Home Administrator on February 20, 2026, at 10:46 a.m. confirmed that there was no documentation in Resident 5's clinical record indicating that the chair and bed alarms were in place.28 Pa.

Code 211.5(f) Clinical Records.

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Embassy of Hillsdale Park 383 Mountain View Drive Hillsdale, PA 15746

corrective plans of action.

current survey, it was determined that the facility's Quality Assurance Performance Improvement

to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending March 6, 2025, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations.

The results of the current survey, ending February 20, 2026, identified repeated deficiencies related the development of individualized care plans, providing quality care, ensuring that the resident's environment was free from accident hazards, and preventing issues with the accountability of controlled medications (drugs with the potential to be abused).

The facility's plan of correction for a deficiency regarding the development of individualized care plans, cited during the survey ending March 6, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review.

The results of the current survey, cited under F-F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that resident's care plans were developed for their individual needs.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending March 6, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review.

The results of the current survey, cited under F-F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free of accident hazards, cited during the surveys ending on March 6, 2025, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring.

The results of the current survey, cited under F-F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the environment was free of accident hazards.

The facility's plans of correction for deficiencies regarding the failure to account for controlled medications, cited during the survey ending March 6, 2025, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance.

The results of the current survey, cited under F-F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.Refer to F-F656, F-F684, F-F689, F75528 Pa.

Code 201.14(a) Responsibility of Licensee.28 Pa.

Code 201.18(e)(1) Management.

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Embassy of Hillsdale Park 383 Mountain View Drive Hillsdale, PA 15746

Observation of wound care

gloves, applied clean gloves and cleansed the resident's right ankle with Dakin's solution and applied

bathroom and washed her hands.

Licensed Practical Nurse 5 then donned clean gloves, removed the sock on the resident's left foot, removed her gloves, applied clean gloves, applied skin prep to the resident's left heel, and removed her gloves.

She then proceeded to clean up her supplies and put items back on the treatment cart.

She exited the resident's room without performing hand hygiene.Interview with Licensed Practical Nurse 5 on February 20, 2026, at 9:07 a.m. revealed she should have worn a gown while providing wound care to Resident 26, however she did not because there were no supplies on the unit to use.

She revealed that she washed her hands twice during wound care, although handwashing was only observed once, and that she did not wash her hands after completing the resident's wound care and before or immediately after exiting the resident's room and going into another resident's room. An interview with the Nursing Home Administrator on February 20, 2026, at 10:48 a.m. confirmed that a gown should have been worn during Resident 26's wound care, hand hygiene should have been performed each time gloves were removed, and that hand hygiene should have been performed after completion of wound care. 28 Pa.

Code 211.12(d)(1)(5) Nursing Services.