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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF HILLSDALE PARK
Inspection Results For:

There are 124 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 Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey, completed on February 20. 2026, it was determined that Embassy 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:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility policies, as well observations and staff interviews, it was determined that the facility failed to maintain an environment free of potential safety hazards related to the facility's hot water temperatures.

Findings include:

A facility policy for safe water temperatures, dated April 3, 2025, included that water temperatures will be set to temperatures of no more than 120 degrees Fahrenheit (F), or the state's allowable maximum water temperature.

Observation made in the bathroom sink in room 115 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 119 and 121 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 119 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 206 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.

Plan of Correction - To be completed: 03/20/2026

Facility failed to maintain an environment free of potential safety hazards related to facility's hot water temperatures.
The facility confirmed that there were no skin issues or injuries related to water temperatures for any residents or staff during the survey. The Director of Maintenance made adjustments to the mixing valves to correct the hot water temperature.
Director of Maintenance or Designee will review 3 random sinks/location weekly for 3 weeks, then monthly for 1 month to ensure water temperatures do not exceed maximum of 110 degrees Fahrenheit. Ongoing routine monitoring of water temperatures will continue as part of a preventative maintenance program to ensure that the water temperatures are maintained at a safe level no less than weekly by Maintenance Director or designee.
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.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment by ensuring that residents' wheelchairs were in good repair for one of 33 residents reviewed (Resident 61).

Findings include:

The facility's policy for safe and homelike environment dated April 3, 2025, revealed that the facility will provide a safe, clean, comfortable and homelike environment.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated February 1, 2026, indicated that the resident was cognitively impaired, required assistance from staff for daily care tasks, used a scoot and go wheelchair, and had diagnoses that included Paranoid schizophrenia and dementia.

Observations of Resident's 61 scoot and go wheelchair on February 17, 2026, at 12:59 p.m. revealed that the leather on both arm rests had black tape wrapped around them.

Observation of Resident's 61 scoot and go wheelchair on February 19, 2026, at 2:25 p.m. revealed that the leather on both arm rests had black tape wrapped around them.

Interview with the Nursing Home Administrator on February 19, 2026, at 2:25 p.m. confirmed that Resident 61's scoot and go wheelchair had black tape around the leather armrests should have been repaired or replaced.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 207.2(a) Administrator's responsibility.

Plan of Correction - To be completed: 03/20/2026

The facility failed to provide safe and homelike environment for Resident 61. Housekeeping Supervisor cleaned Resident 61 wheelchair and Maintenance Director replaced both arm rests on Resident 61 chair.
Director of Nursing or designee will complete full house audit for residents with wheelchairs to ensure they are clean and in good repair. Licensed Nursing Home Administrator will review the policy for wheelchair cleaning, and providing a safe and homelike environment with Nursing Staff, and re-educate on reporting wheelchairs that are in disrepair and requiring attention.
Director of Nursing or Designee will review 3 random residents weekly for 3 weeks, then monthly for 1 month to ensure wheelchairs in clean and in good repair.
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.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to notify the resident and/or the resident's representative, in writing regarding the reason for transfer to the hospital and failed to notify the ombudsman of the transfer to the hospital, for one of 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.

Plan of Correction - To be completed: 03/20/2026

The facility failed to notify Resident 5 and/or Resident 5 Representative, in writing regarding the reason for transfer to the hospital and failed to notify the Ombudsman of the transfer to the hospital.
Director of Nursing or Designee will speak with resident 5 Representative to notify of transfer to the hospital and reasoning, and notify that any future transfers would also have written notification for review. Nursing Home Administrator or designee will ensure that transfers are sent to the Ombudsman. Licensed Nursing Home Administrator reviewed Regulation, and now has it in place for all resident transfers. Nursing staff be re-educated on the process for notification of responsible parties regarding hospital transfers.
Director of Nursing or Designee will review hospital transfers weekly for 2 weeks, then monthly for 1 month to ensure that proper written notice is sent to Ombudsman and monitor that notifications to responsible parties are made regarding hospital transfers
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.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement an individualized care plan for one of 33 residents reviewed (Resident 9).

Findings include:

The facility's policy regarding care plans, dated April 3, 2025, 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.

Plan of Correction - To be completed: 03/20/2026

The facility failed to develop and implement an individualized care plan for Resident 9. Nursing staff re-educated to ensure that a care plan is also in place for residents with chronic diarhhea and related diagnoses.
Director of Nursing or designee will complete full house audit for residents receiving anti-diarrheal medication to ensure that they have a care plan in place for diarrhea.
Director of Nursing or Designee will review 3 random residents weekly for 3 weeks, then monthly for 1 month to ensure if new order is in place for antidiarrheal medication, that a care plan is in place.
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.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for one of 33 residents reviewed (Resident 68).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a 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.

Plan of Correction - To be completed: 03/20/2026

The facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for Resident 68.
Director of Nursing or Designee will complete full house audit of residents ordered Coreg to ensure that parameters are in place and followed. Nursing staff re-educated on following medication parameters if ordered by the physician.
Director of Nursing or Designee will review 3 random residents weekly for 3 weeks, then monthly for 1 month to ensure if new order is in place for Coreg, that parameters are in place and followed per Physician's Orders.
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.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 33 residents reviewed (Resident 77).

Findings include:

The facility's policy for 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.

Plan of Correction - To be completed: 03/20/2026

Facility failed to ensure the accountability of controlled medications for Resident 77.
Director of Nursing or Designee will educate licensed staff on the destruction/disposal of controlled medications which should include a licenses nurse and a licensed pharmacist or authorized nurse supervisor.
Director of Nursing or Designee will review 3 random residents weekly for 3 weeks, then monthly for 1 month for discharge to ensure controlled medications are disposed of properly.
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.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured 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.

Plan of Correction - To be completed: 03/20/2026

Facility failed to ensure that medications were properly secured in a medication cart.
Director of Nursing or Designee will educate nursing staff to ensure that the policy for secured medications is reviewed. Nursing staff re-educated that they need to ensure that the medication room door is locked when licensed staff are not in the medication room.
Director of Nursing or Designee will review 3 random nurses weekly for 3 weeks, then monthly for 1 month to ensure medication carts are locked and medications are stored properly.
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.

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 33 residents reviewed (Residents 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 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.

Plan of Correction - To be completed: 03/20/2026

Facility failed to ensure that residents' clinical records were complete and accurately documented for Resident 5.
Director of Nursing or Designee will complete full house audit for chair and bed alarms for residents to ensure that there is documentation in place for placement and functional status. Nursing staff re-educated on the need to ensure that documentation is in place for resident's that are ordered/care planned for bed/chair alarms.
Director of Nursing or Designee will review new orders for chair and bed alarms weekly for 3 weeks and monthly for 1 month to ensure that documentation is in place for placement and functional status.
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.

483.75(c)(1)-(4)d)(1)(2)(e)(1)-(3)(g)(2)(ii)(iii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans 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 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 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 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 F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

Refer to F656, F684, F689, F755

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

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

Plan of Correction - To be completed: 03/20/2026

Licensed Nursing Home Administrator educated Department Managers on the repeat deficiencies regarding 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).
Licensed Nursing Home Administrator will educate all in attendance at the Quality Assurance Performance Improvement Meeting on deficiencies 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).
Licensed Nursing Home Administrator will oversee audits for plan of correction.
Results of audits will be reviewed in the facility Quality Assurance Performance Improvement Meeting. The Facility Quality Assurance Performance Committee will continue to review and monitor deficiencies in order to ensure that corrective actions are sustained ongoing.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of policies and clinical records, as well as interviews with staff, it was determined that the facility failed to maintain professional practices that support infection prevention and control for three of 33 residents reviewed (Residents 7, 11, and 26).

Findings include:

The facility policy regarding hand hygiene, dated April 3, 2026, included that hand hygiene is a general term for cleaning your hands with soap and water or the use of an antiseptic hand rub. The use of gloves does not replace hand hygiene. If the task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

The facility policy regarding medication administration, dated April 3, 2026, included that medications are administered by licensed nurses or other staff that are licensed to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Wash hands prior to administering medication per facility policy and product. Remove medication from its source, taking care not to touch medication with bare hands.

The facility policy regarding enhanced barrier precautions (EBP), dated April 3, 2026, revealed that the facility would implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms (MDRO). Enhanced barrier precautions refer to the use of a gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at an increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). The facility was to make gowns and gloves available immediately outside of the resident's room. High contact care activities include wound care: any skin opening requiring dressing. EBP will be used for the duration of the affected resident's stay in the facility or until resolution of the wound heals or the indwelling medical device is removed.

Observation of medication administration for Resident 7 on February 20, 2026, at 6:43 a.m. revealed that Licensed Practical Nurse 3 donned gloves and administered eye drops to the resident. Upon completion of the administration of the eye drops, the Licensed Practical Nurse removed her gloves and proceeded to the medication cart and prepared and administered medications to another resident. Licensed Practical Nurse 3 did not complete hand hygiene after removing her gloves or before preparing and administering medication to the next resident. During an interview with Licensed Practical Nurse 3 on February 20, 2026, at 6:55 a.m. she stated " I don't think we have to clean our hands between every resident. I am very careful not to touch anything with my bare hands."

Observation of medication administration for Resident 11 on February 20, 2026, at 6:35 a.m. revealed that Licensed Practical Nurse 4 dropped a small white pill on the top of the medication cart when preparing the resident's medication then picked the pill up with her bare hands and placed it in a medication cup with other medications. Licensed Practical Nurse 4 proceeded into the resident's room and administered the medication. Interview with Licensed Practical Nurse 4 at the time of the observation confirmed that she should not have touched the resident's medication with her bare hands.

An interview with the Nursing Home Administrator on February 20, 2026, at 7:33 a.m. confirmed that pills should not be touched with bare hands, and that hand hygiene should have been performed after glove removal and before providing meds to the next resident.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated January 22, 2026, revealed that the resident was cognitively intact, required assistance with daily care needs, had diagnoses that included diabetes and dementia, and had pressure ulcers.

Physician's orders for Resident 26 dated June 6, 2025, included an order for the resident to have Enhanced Barrier Precautions in place every shift. Gloves and gowns to be worn when providing wound care: chronic wounds such as pressure ulcers, or diabetic foot ulcers. Physician's orders for Resident 26 dated January 9, 2026, included an order for the resident to have skin prep applied to her left heel every day and evening shift for wound care. Physician's orders for Resident 26 dated January 16, 2026, included an order for the resident to have her right ankle cleansed with 0.125 % Dakin's solution (topical antiseptic to cleanse infected wounds), apply calcium alginate (highly absorbent wound dressing), to the wound bed, an ABD pad (abdominal pad-a thick, highly absorbent medical dressing), and rolled gauze daily and as needed for wound care.

Observation of wound care treatment for Resident 26 on February 20, 2026, at 8:51 a.m. revealed that Licensed Practical Nurse 5 donned gloves and removed the soiled dressing from the resident's right ankle. She then removed her gloves, applied clean gloves and cleansed the resident's right ankle with Dakin's solution and applied the calcium alginate, ABD pad, gauze, and tape. She then removed her gloves and went into the 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.

Plan of Correction - To be completed: 03/20/2026

Facility failed to maintain professional practices that support infection prevention and control for Residents 7, 11 and 26.
Director of Nursing or Designee will complete education with nursing staff on infection prevention and control, as well as hand hygiene and Enhanced Barrier Precautions.
Director of Nursing or Designee will complete weekly audits for 2 random nurses for 3 weeks then monthly for 1 month to ensure that staff are observed following infection prevention and control and hand hygiene properly, as well as following the policy for Enhanced Barrier Precautions.
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)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 03/20/2026

The facility failed to provide one nurse aide (NA) per 10 residents on the day shift for 13 of 21 days, failed to provide one NA per 11 residents on the evening shift for 2 of 21 days, and failed to provide a minimum of one NA per 15 residents on the night shift for 2 of 21 days reviewed. 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 facility'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 Stand Up" with attendance of the Nursing Home Administrator, Director of Nursing, Human Resource Director will focus on the following:
Focus on Daily Per Patient Day, 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 Department of Health 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.
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)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 03/20/2026

The facility failed to provide 3.20 hours of direct resident care for each resident for 19 of 21 days (24-hour periods) 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 Stand Up" with attendance of the Nursing Home Administrator, Director of Nursing, Human Resource Director, will focus on the following:
Focus on Daily Per Patient Day, 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 Department of Health 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.

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