Embassy of Hillsdale Park

In the surveyor’s words

From the most serious findings on record at Embassy of Hillsdale Park, in the surveyor’s own words.

• Actual harm, isolatedF580Jul 21, 2026

  Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of six residents reviewed (Resident 2) who required hospitalization for hypoxia, congestive heart failure and pleural effusion.Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 22, 2026, indicated that the resident had severe cognitive impairment, required assistance from staff for daily care needs, and had diagnoses that included heart failure (heart muscle cannot pump blood and oxygen effectively enough to meet the body's needs). A nurse's note for Resident 2 dated April 16, 2026, at 6:35 p.m. […]

• Actual harm, isolatedF600Jun 30, 2022

  Based on review of policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 41 residents reviewed (Resident 62). Findings include: The facility's abuse policy, dated March 11, 2022, indicated that the facility would not tolerate abuse, neglect and exploitation of its residents or misappropriation of resident property. The facility would investigate all alleged violations involving abuse, neglect, exploitation and mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Jun 30, 2022

  Based on review of facility policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible for one of 41 residents reviewed (Resident 42) who used assist rails, resulting in a fracture, failed to follow physician-ordered and care-planned interventions for one of 41 residents reviewed (Resident 38), and failed to complete thorough investigations of falls to determine the possible cause(s) for one of 41 residents reviewed (Resident 38). […]

• No harm, potential for more than minimal, patternF684Jul 21, 2026

  Based on facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow physician's orders for one of six residents reviewed (Residents 2). Findings include: A facility policy for medication administration dated June 17, 2026, included that medications are administered by licensed nurses or other staff who are legally authorized 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 and infection. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. […]

• No harm, potential for more than minimal, patternF689Feb 20, 2026

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