Pennsylvania Department of Health
EMBASSY OF HILLSDALE PARK
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EMBASSY OF HILLSDALE PARK
Inspection Results For:

There are  110 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
EMBASSY OF HILLSDALE PARK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on March 20, 2024, it was determined that Emassy of Hillsdale Park was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:


Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of five residents reviewed (Resident 3).

Findings include:

A facility policy for resident showers indicated that residents will be provided showers as per request or as per facility schedule protocols.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 21, 2024, indicated that the resident was cognitively impaired, was dependent on staff for showers and bathing, and had diagnoses that included peripheral vascular disease.

A care plan for Resident 3, dated December 12, 2023, indicated that the resident required two staff members to provide care. A care plan, dated January 1, 2024, indicated that the resident was to be assisted with showering as per facility policy weekly.

A review of the facility shower schedule indicated that Resident 3 was to have a shower every Wednesday and Saturday on day shift.

Review of bathing documentation for Resident 3, dated February 20, 2024, through March 19, 2024, indicated that the resident only received two showers during that time. There was no documented evidence that the resident was offered or refused showers weekly as per his care plan.

Observations of Resident 3 on March 20, 2024, at 11:00 a.m. revealed that the resident lying in bed with his eyes closed. Observations on March 20, 2024, at 3:45 p.m. revealed that the resident was lying in bed with several visitors in his room.

Interview with Nurse Aide 3 on March 20, 2024, at 11:05 a.m. revealed that she was the only nurse aide providing care on the North Shore unit and that she was not able to complete her scheduled resident showers. She reported this as a common occurrence and sometimes was unable to get residents out of bed if she could not find help from other staff.

Interview with Licensed Practical Nurse 1 on March 20, 2024, at 11:30 a.m. revealed that only one nurse aide was working on the West Shore unit; therefore, Resident 3 was not able to be provided his scheduled shower that day.

Interview with Nurse Aide 2 on March 20, 2024, at 11:45 a.m. revealed that she was the only nurse aide providing care on the West Shore unit and that she was not able to provide the scheduled resident showers on that unit that day.

Interview with the Nursing Home Administrator on March 20, 2024, at 4:00 p.m. confirmed that there was no documented evidence that Resident 3 was offered or refused showers weekly from February 20, 2024, through March 19, 2024, per the resident's care plan.

28 Pa. Code 211.12(d)(5) Nursing Services.



 Plan of Correction - To be completed: 04/12/2024

The facility failed to ensure that showers were provided as scheduled for 1 of 5 residents reviewed. Resident 3 was interviewed as well as Resident 3's family, and it was determined that he is receiving showers on a regular basis. No evidence exists of any alterations in skin integrity or any negative affect to Resident 3 upon review.
Director of Nursing or Designee will review shower schedule for Resident R3 for the prior day for 5 days to ensure that showers were completed per policy and resident preferences.
A full house audit was completed for residents and shower schedules were placed in nurse aide documentation to ensure going forward that there is evidence documented on showers and refusals of showers.
Director of Nursing or Designee will review shower schedule for prior days showers and will perform random audits of 3 residents weekly for 3 weeks. Trending and monitoring data/information will be reviewed at the monthly Quality Assurance and Performance Improvement Committee Meeting for further discussion and recommendations by all in attendance.
211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:


Based on review of nursing schedules and staffing information furnished by the facility, as well as staff interviews, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents on the day shift for 12 of 21 days, failed to ensure a minimum of one nurse aide per 12 residents on the evening shift for 10 of 21 days, and failed to ensure a minimum of one nurse aide per 20 residents on the overnight shift for 17 of 21 days (24-hour periods) reviewed.

Findings include:

Review of facility census data indicated that on February 11, 2024, the facility census was 69, which required 3.45 (69 residents divided by 20) nurse aides (NA's) during the overnight shift. Review of the nursing time schedules revealed 3.09 NA's provided care during the overnight shift on February 11, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 12, 2024, the facility census was 69, which required 3.45 NA's during the overnight shift. Review of the nursing time schedules revealed 2.88 NA's provided care during the overnight shift on February 12, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 13, 2024, the facility census was 68, which required 5.67 (68 residents divided by 12) NA's during the day shift. Review of the nursing time schedules revealed 5.59 NA's provided care on the day shift on February 13, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 14, 2024, the facility census was 70, which required 5.83 NA's during the day shift. Review of the nursing time schedules revealed 5.58 NA's provided care on the day shift on February 14, 2024. The facility census was 70, which required 3.50 NA's during the overnight shift. Review of the nursing time schedules revealed 2.74 NA's provided care during the overnight shift on February 14, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 15, 2024, the facility census was 70, which required 5.83 (70 residents divided by 12) NA's during the evening shift. Review of the nursing time schedules revealed 4.34 NA's provided care on the evening shift on February 15, 2024. The facility census was 70, which required 3.50 NA's during the overnight shift. Review of the nursing time schedules revealed 3.06 NA's provided care during the overnight shift on February 15, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 16, 2024, the facility census was 70, which required 5.83 NA's during the day and evening shift. Review of the nursing time schedules revealed 5.67 NA's provided care on the day shift and 5.74 NA's provided care on the evening shift on February 16, 2024. The facility census was 70, which required 3.50 NA's during the overnight shift. Review of the nursing time schedules revealed 3.35 NA's provided care during the overnight shift on February 16, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 25, 2024, the facility census was 67, which required 5.58 NA's during the day shift. Review of the nursing time schedules revealed 5.35 NA's provided care on the day shift on February 25, 2024. The facility census was 67, which required 3.35 NA's during the overnight shift. Review of the nursing time schedules revealed 3.31 NA's provided care during the overnight shift on February 25, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 26, 2024, the facility census was 67, which required 5.58 NA's during the day shift. Review of the nursing time schedules revealed 5.14 NA's provided care on the day shift. The facility census was 66, which required 5.50 NA's during the evening shift. Review of the nursing time schedules revealed 5.12 NA's provided care on the evening shift on February 26, 2024. The facility census was 66, which required 3.30 NA's during the overnight shift. Review of the nursing time schedules revealed 3.11 NA's provided care during the overnight shift on February 26, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 27, 2024, the facility census was 65, which required 5.42 NA's during the evening shift. Review of the nursing time schedules revealed 4.67 NA's provided care on the evening shift on February 27, 2024. The facility census was 65, which required 3.25 NA's during the overnight shift. Review of the nursing time schedules revealed 2.74 NA's provided care during the overnight shift on February 27, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 28, 2024, the facility census was 65, which required 5.42 NA's during the evening shift. Review of the nursing time schedules revealed 5.32 NA's provided care on the evening shift on February 28, 2024. The facility census was 65, which required 3.25 NA's during the overnight shift. Review of the nursing time schedules revealed 2.80 NA's provided care during the overnight shift on February 28, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 29, 2024, the facility census was 65, which required 5.42 NA's during the day shift. Review of the nursing time schedules revealed 4.68 NA's provided care on the day shift on February 29, 2024. The facility census was 65, which required 3.25 NA's during the overnight shift. Review of the nursing time schedules revealed 2.57 NA's provided care during the overnight shift on February 29, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 1, 2024, the facility census was 65, which required 3.25 NA's during the overnight shift. Review of the nursing time schedules revealed 2.52 NA's provided care on the overnight shift on March 1, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 2, 2024, the facility census was 64, which required 5.33 NA's during the evening shift. Review of the nursing time schedules revealed 5.13 NA's provided care on the evening shift on March 2, 2024. The facility census was 64, which required 3.20 NA's during the overnight shift. Review of the nursing time schedules revealed 3.10 NA's provided care on the overnight shift on March 2, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 3, 2024, the facility census was 64, which required 5.33 NA's during the day shift. Review of the nursing time schedules revealed 5.06 NA's provided care on the day shift on March 3, 2024. The facility census was 64, which required 3.20 NA's during the overnight shift. Review of the nursing time schedules revealed 2.69 NA's provided care on the overnight shift on March 3, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 4, 2024, the facility census was 64, which required 5.33 NA's during the day shift. Review of the nursing time schedules revealed 5.10 NA's provided care during the day shift. The facility census was 63, which required 5.25 NA's during the evening shift. Review of the nursing time schedules revealed 3.03 NA's provided care during the evening shift on March 4, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 5, 2024, the facility census was 63, which required 5.25 NA's during the day shift. Review of the nursing time schedules revealed 5.03 NA's provided care on the day shift on March 5, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 6, 2024, the facility census was 63, which required 5.25 NA's during the day shift. Review of the nursing time schedules revealed 4.13 NA's provided care on the day shift on March 6, 2024. The facility census was 65, which required 3.25 NA's during the overnight shift. Review of the nursing time schedules revealed 3.17 NA's provided care on the overnight shift on March 6, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 7, 2024, the facility census was 65, which required 5.42 NA's during the day shift. Review of the nursing time schedules revealed 5.10 NA's provided care on the day shift on March 7, 2024. The facility census was 65, which required 5.42 NA's during the evening shift. Review of the nursing time schedules revealed 5.10 NA's provided care during the evening shift on March 7, 2024. The facility census was 65, which required 3.25 NA's during the overnight shift. Review of the nursing time schedules revealed 2.18 NA's provided care on the overnight shift on March 7, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 8, 2024, the facility census was 65, which required 5.42 NA's during the day shift. Review of the nursing time schedules revealed 5.13 NA's provided care on the day shift on March 8, 2024. The facility census was 66, which required 5.50 NA's during the evening shift. Review of the nursing time schedules revealed 5.13 NA's provided care during the evening shift on March 8, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 9, 2024, the facility census was 66, which required 5.50 NA's during the evening shift. Review of the nursing time schedules revealed 5.15 NA's provided care during the evening shift on March 9, 2024. The facility census was 66, which required 3.30 NA's during the overnight shift. Review of the nursing time schedules revealed 2.77 NA's provided care on the overnight shift on March 9, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Nursing Home Administrator on March 20, 2024, at 4:00 p.m. confirmed that the facility did not meet the required nurse aide-to-resident staffing ratios for the days listed above.



 Plan of Correction - To be completed: 04/12/2024

The facility did not ensure a minimum of one nurse aide to resident ratio on day shift for 12 of 21 days, on the afternoon shift for 10 of 21 days, and overnight shifts for 17 of 21 days. The facility cannot retroactively correct the identified days the facility did not ensure the correction staffing ratio.
No evidence exists of any residents having any potential to be affected by this deficient practice.
Upon review of the facilty's current process for staffing review, the following steps and system changes have been implemented to ensure all steps are being taken to meet the current ratio requirements.
During the current "Daily Labor Meeting" with attendance of the Nursing Home Administrator, Director of Nursing, Human Resource Director and Scheduler, will focus on the following:
Focus on Daily PPD, ratio requirements, daily needs, future needs for clinical coverage and the safety of the residents.
Review of daily/weekly schedules
Daily completion of the newly revised DOH Nursing Staff Ratio form. Form will be completed during meeting and decisions on staffing ratio will be made.
The facility continue to explore all avenues for staff needs, i.e., active recruitment efforts, and bonus program have been exhausted.
A regional recruiter has been hired to assist in the recruitment of all clinical staff in an effort to both hire and retain staff to ensure the safety and well-being of our residents.
Nursing Home Administrator and Director of Nursing will evaluate admissions based on the staffing needs of the facility.
Daily actions will be monitored by the Director of Nursing and Nursing Home Administrator during our ongoing daily labor meetings and make decisions of the corrective actions to be taken. Trending and monitoring data/information will be reported daily at the morning leadership team meeting and at the monthly Quality Assurance and Performance Improvement Committee Meeting for further discussion and recommendations by all in attendance.
211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:


Based on review of nursing schedules and staffing information furnished by the facility, as well as staff interviews, it was determined that the facility failed to ensure a minimum of one Licensed Practical Nurse (LPN) per 25 residents on the day shift for two of 21 days, failed to ensure a minimum of one LPN per 30 residents on the evening shift for one of 21 days, and failed to ensure a minimum of one LPN per 40 residents on the overnight shift for one of 21 days (24-hour periods) reviewed.

Findings include:

Review of facility census data indicated that on February 12, 2024, the facility census was 68, which required 1.70 LPN's during the overnight shift. Review of the nursing time schedules revealed 1.61 LPN's provided care on the overnight shift on February 12, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 16, 2024, the facility census was 70, which required 2.33 LPN's during the evening shift. Review of the nursing time schedules revealed 2.16 LPN's provided care on the evening shift on February 16, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on February 27, 2024, the facility census was 65, which required 2.60 LPN's during the day shift. Review of the nursing time schedules revealed 2.09 LPN's provided care on the day shift on February 27, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Review of facility census data indicated that on March 6, 2024, the facility census was 63, which required 2.52 LPN's during the day shift. Review of the nursing time schedules revealed 2.13 LPN's provided care on the day shift on March 6, 2024. No additional excess higher-level staff were available to compensate for this deficiency.

Interview with the Nursing Home Administrator on March 20, 2024, at 4:00 p.m. confirmed that the facility did not meet the required LPN-to-resident staffing ratios for the day listed above.



 Plan of Correction - To be completed: 04/12/2024

The facility did not ensure a minimum of one Licensed Practical Nurse to resident ratio on day shift for 2 of 21 days, on the afternoon shift for 1 of 21 days, and overnight shifts for 1 of 21 days. The facility cannot retroactively correct the identified days the facility did not ensure the correction staffing ratio.
No evidence exists of any residents having any potential to be affected by this deficient practice.
Upon review of the facilty's current process for staffing review, the following steps and system changes have been implemented to ensure all steps are being taken to meet the current ratio requirements.
During the current "Daily Labor Meeting" with attendance of the Nursing Home Administrator, Director of Nursing, Human Resource Director and Scheduler, will focus on the following:
Focus on Daily PPD, ratio requirements, daily needs, future needs for clinical coverage and the safety of the residents.
Review of daily/weekly schedules
Daily completion of the newly revised DOH Nursing Staff Ratio form. Form will be completed during meeting and decisions on staffing ratio will be made.
The facility continue to explore all avenues for staff needs, i.e., active recruitment efforts, and bonus program have been exhausted.
A regional recruiter has been hired to assist in the recruitment of all clinical staff in an effort to both hire and retain staff to ensure the safety and well-being of our residents.
Nursing Home Administrator and Director of Nursing will evaluate admissions based on the staffing needs of the facility.
Daily actions will be monitored by the Director of Nursing and Nursing Home Administrator during our ongoing daily labor meetings and make decisions of the corrective actions to be taken. Trending and monitoring data/information will be reported daily at the morning leadership team meeting and at the monthly Quality Assurance and Performance Improvement Committee Meeting for further discussion and recommendations by all in attendance.
211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:


Based on review of nursing schedules and staff interviews, it was determined that the facility failed to provide 2.87 hours of direct resident care for each resident for nine of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules provided by the facility for the weeks of February 11 through 17, 2024, and February 25 through March 9, 2024, revealed that the facility provided only 2.74 hours of direct care for each resident on February 15, 2.75 hours of direct care for each resident on February 16, 2.64 hours of direct care for each resident on February 17, 2.81 hours of direct care for each resident on February 26, 2.78 hours of direct care for each resident on February 27, 2.73 hours of direct care for each resident on March 5, 2.76 hours of direct care for each resident on March 6, 2.80 hours of direct care for each resident on March 7, and 2.86 hours of direct care for each resident on March 9.

Interview with the Nursing Home Administrator on March 20, 2024, at 4:00 p.m. confirmed that the facility did not meet the required daily hours of direct resident care for each resident on the days listed above.



 Plan of Correction - To be completed: 04/12/2024

The facility did not ensure a minimum of 2.87 hours of direct resident care for each resident for 9 out of 21 days reviewed. The facility cannot retroactively correct the identified days the facility did not ensure the correction staffing minimums.
No evidence exists of any residents having any potential to be affected by this deficient practice.
Upon review of the facilty's current process for staffing review, the following steps and system changes have been implemented to ensure all steps are being taken to meet the current ratio requirements.
During the current "Daily Labor Meeting" with attendance of the Nursing Home Administrator, Director of Nursing, Human Resource Director and Scheduler, will focus on the following:
Focus on Daily PPD, ratio requirements, daily needs, future needs for clinical coverage and the safety of the residents.
Review of daily/weekly schedules
Daily completion of the newly revised DOH Nursing Staff Ratio form. Form will be completed during meeting and decisions on staffing ratio will be made.
The facility continue to explore all avenues for staff needs, i.e., active recruitment efforts, and bonus program have been exhausted.
A regional recruiter has been hired to assist in the recruitment of all clinical staff in an effort to both hire and retain staff to ensure the safety and well-being of our residents.
Nursing Home Administrator and Director of Nursing will evaluate admissions based on the staffing needs of the facility.
Daily actions will be monitored by the Director of Nursing and Nursing Home Administrator during our ongoing daily labor meetings and make decisions of the corrective actions to be taken. Trending and monitoring data/information will be reported daily at the morning leadership team meeting and at the monthly Quality Assurance and Performance Improvement Committee Meeting for further discussion and recommendations by all in attendance.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port