Inspection·March 20, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Few Findings include: A facility policy for resident showers dated March 14, 2024, 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 [NAME] Shore unit; therefore, Resident 3 was not able to be provided his scheduled shower that day. (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395569 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395569 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Hillsdale Park 383 Mountain View Drive Hillsdale, PA 15746 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)