Cycle 1
Health 2025-03-06 · Fire 2025-03-06
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Hillsdale, PA
Embassy Of Hillsdale Park
2-star overall rating with 2-star inspections with abuse icon flag with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
383 Mountain View Drive, Hillsdale, PA
(814) 743-6613
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Embassy Healthcare
Operator or chain grouping
Approved since
1983-01-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing
LPN hours / resident day
0.84
Licensed practical nurse staffing
Aide hours / resident day
1.86
Nurse aide staffing
Weekend hours
3.01
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
31%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.2
0.6 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
86.9%
7.2 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
93.5%
3.6 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.2%
0.7 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.2% |
6.5%
0.7 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.6% |
19.9%
17.7 pts worse
|
19.6%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 58.5% |
18.7%
39.8 pts worse
|
16.7%
41.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.7% |
19.6%
7.9 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
18.3%
8.8 pts better
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.5% |
26.4%
4.9 pts better
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.7% |
5.3%
3.4 pts worse
|
5.1%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.1% |
68.9%
1.2 pts better
|
81.7%
11.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.9% |
9.8%
1.9 pts better
|
12.0%
4.1 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.5%
1.8 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.8% |
68.7%
5.1 pts better
|
79.7%
5.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
23.1%
4.4 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2024-04-11
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
10 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-06
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-03-31
D · Potential for more than minimal harm
2025-03-06
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-31
B · Minimal harm
2025-03-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-31
F · Potential for more than minimal harm
2024-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-01
F · Potential for more than minimal harm
2024-04-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-01
C · Minimal harm
2024-04-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-01
F · Potential for more than minimal harm
2023-05-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-06-30
B · Minimal harm
2023-05-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-18
E · Potential for more than minimal harm
2024-04-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-11
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-03-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-12
D · Potential for more than minimal harm
2023-05-11
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-11
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-11
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-01
E · Potential for more than minimal harm
2023-03-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-30
Penalties and ownership
What sits behind the stars
Ownership
Embassy Pa Tenant 2 Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
2020 Gsr Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Aaron Handler Family Dynasty Trust
5% Or Greater Indirect Ownership Interest · Organization
Ah Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Embassy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Embassy Healthcare Management Inc
Operational/Managerial Control · Organization
George S. Repchick 2020 Family Dynasty Trust
5% Or Greater Indirect Ownership Interest · Organization
Handler, Aaron
Operational/Managerial Control · Individual
Heritage Employment Services, LLC
Operational/Managerial Control · Organization
Repchick, George
Operational/Managerial Control · Individual
Roscoe, Brandon
Operational/Managerial Control · Individual
Rowles, Shannon
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Haida Nursing And Rehab
Hastings, PA
2-star overall rating with 2-star inspections with $32,711 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Mulberry Healthcare And Rehabilitation Cent
Punxsutawney, PA
1-star overall rating with 1-star inspections with $24,042 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Communities At Indian Haven,
Indiana, PA
2-star overall rating with 2-star inspections with abuse icon flag with $8,281 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out