Embassy Of East Mountain
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilkes-barre, Pennsylvania.
- Location
- 101 East Mountain Drive, Wilkes-barre, Pennsylvania 18702
- CMS Provider Number
- 395706
- Inspections on file
- 35
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Embassy Of East Mountain during CMS and state inspections, most recent first.
A resident's personal funds were not returned within the required 30-day period after discharge. Financial records showed a substantial credit balance remained months after the resident left, and staff confirmed the delay was due to changes in business office management.
The facility failed to create individualized discharge plans for two residents, both cognitively intact, who expressed desires to return home. One resident discharged against medical advice, while the other sought waiver services. The facility did not update care plans to reflect these goals, as confirmed by staff interviews.
The facility failed to maintain clear hallways, with linen carts, PPE storage bins, and equipment obstructing handrails in three resident hallways. These obstructions were confirmed by the Nursing Home Administrator, acknowledging the safety hazards created for residents, staff, and visitors.
The facility failed to securely store oxygen cylinders, with seven full and five empty tanks found unsecured in the hallway. Despite having a designated storage area outside, a Maintenance Assistant stored the tanks inside for convenience, contrary to facility policy. The Nursing Home Administrator acknowledged the non-compliance.
The facility failed to provide timely pharmacy services, resulting in medication administration delays for three residents. A resident with anxiety did not receive Clonazepam due to pharmacy delivery delays. Another resident, post-hospitalization for fractures, did not receive prescribed Oxycodone for pain management, leading to increased confusion and pain. A third resident did not receive essential medications due to pharmacy delays. The facility lacked a backup emergency pharmacy and proper oversight of the medication dispensing system.
The facility failed to ensure proper oversight and management of its automated medication system, leading to missed medication doses for several residents. The lack of pharmacist supervision, system inspections, and medication accountability resulted in medication availability issues and delays in administration. The Nursing Home Administrator confirmed non-compliance with Pennsylvania code regarding pharmacy services.
A facility failed to ensure an accurate MDS assessment for a resident with dementia and oropharyngeal dysphagia. The resident had orders for enteral feeding via a PEG tube and a liquid diet for pleasure feeding, but the MDS inaccurately indicated no feeding tube. This discrepancy was confirmed by the DON.
A resident with anxiety and depression expressed suicidal thoughts and was hospitalized for psychiatric evaluation. Despite this change in condition, the facility did not refer the resident for a PASRR Level II evaluation, as confirmed by staff interviews.
A facility failed to update a resident's care plan after incidents of suicidal ideation and self-harm. Despite hospitalization and a self-inflicted injury, the care plan was not revised to address the resident's current needs. The DON confirmed the oversight.
A resident with diabetes and congestive heart failure was not placed on a restorative ambulation program as recommended by therapy, despite expressing a desire to walk more frequently. The facility's failure to implement the program was confirmed by the DON, with no evidence found in the resident's care plan or clinical record.
The facility failed to provide necessary therapeutic social services to two residents, impacting their mental and psychosocial well-being. One resident, with a history of alcoholism and suicidal ideations, expressed a desire to be discharged, but no social services addressed this conflict. Another resident, with anxiety and depression, had no documented therapeutic interventions despite a history of suicidal ideation and self-harming behaviors.
The facility failed to offer routine annual dental services to two private payor source residents. One resident, with Alzheimer's and COPD, was severely cognitively impaired, and another had Alzheimer's and muscle weakness. There was no documented evidence that their responsible parties were offered dental services in the past year, as confirmed by the DON.
A facility failed to offer routine annual dental services to a Medicaid resident with dementia and congestive heart failure. The resident's MDS assessment showed moderate cognitive impairment, and there was no documentation that the responsible party was offered dental services in the past year. This was confirmed by the DON.
The facility failed to coordinate hospice services with facility care for two residents, one with cerebral infarct and another with end-stage COPD. Their care plans lacked integration with hospice services, as confirmed by the DON, indicating a deficiency in managing hospice care coordination.
The facility failed to resolve resident complaints about cold shower water temperatures and the lack of evening snacks, despite repeated grievances voiced during Resident Council and Food Committee meetings. The NHA and DON could not provide documentation of effective measures taken to address these issues.
The facility failed to ensure that dependent residents were provided with necessary services to maintain good personal hygiene, specifically by not providing scheduled showers and neglecting personal grooming for three residents. Interviews with the DON and NHA confirmed the inconsistency in providing scheduled showers, and there was no documentation of refusals or reasons for not showering the residents as scheduled.
The facility failed to maintain a safe environment as the 100 East hallway was obstructed by various items, blocking access to handrails, and a treatment cart containing wound care equipment was found unattended and unlocked. The NHA and DON confirmed these issues, creating potential accident hazards.
The facility failed to administer oxygen as ordered and maintain sanitary oxygen delivery systems for a resident. The resident received oxygen at 4 L/min instead of the prescribed 3 L/min, and the oxygen setup was not dated. The CPAP mask was improperly stored, and the nasal cannula was re-applied without cleaning after being on the floor. Undated oxygen equipment from a discharged resident was also found in a room occupied by other residents.
The facility failed to maintain sanitary practices for food storage and service, including issues such as dust on vents, dirt on floors, missing tiles, a malfunctioning freezer door, and visibly soiled utility carts. These deficiencies increased the risk of food-borne illness.
The facility failed to conduct a significant change MDS assessment for a resident who experienced a significant decline and was placed on hospice care. Despite the resident being discontinued from hospice services, no significant change MDS assessment was completed as required.
The facility failed to ensure the MDS Assessments accurately reflected a resident's status. An annual MDS Assessment incorrectly indicated that the resident did not require a Level II PASRR process, despite previous documentation confirming the need for specialized services. This was confirmed by the social services director.
The facility failed to update the care plan for a resident with COPD after the discontinuation of Hospice services. Despite the significant change in care needs, the care plan was not revised to ensure appropriate interventions were implemented. This was confirmed by the DON.
The facility failed to develop and implement an individualized person-centered plan for a resident with dementia who exhibited severe cognitive impairment and behavioral symptoms. The care plan did not include specific behaviors or interventions, and there was no evidence of necessary care and services, including non-pharmacological approaches and specialized supports. The Nursing Home Administrator confirmed the deficiency.
Failure to Timely Return Discharged Resident's Personal Funds
Penalty
Summary
The facility failed to return the personal funds of a discharged resident within the required 30-day period. Clinical record review showed that the resident was admitted and later discharged, but a review of the resident's financial account statement revealed a significant credit balance remained months after discharge, indicating the funds had not been disbursed as required. An email from the Regional Business Office Manager confirmed that the facility's Business Office Manager had been terminated, and the refund process was delayed as a result. The Director of Nursing also confirmed that the resident's personal funds were not returned within the mandated timeframe.
Failure to Implement Individualized Discharge Plans
Penalty
Summary
The facility failed to develop and implement individualized discharge plans for two residents, Resident 252 and Resident 81, which did not reflect their discharge goals. Resident 251, who was cognitively intact with a BIMS score of 15, expressed a desire to be discharged home, as documented in a social service note. However, there was no documented evidence that the facility addressed this desire or the conflicting wish of the resident's wife for him to remain in the facility. The resident eventually discharged himself against medical advice, and the comprehensive care plan lacked any updates or revisions to reflect his discharge goals. Similarly, Resident 81, also cognitively intact with a BIMS score of 15, expressed a desire to return home with waiver services. Despite the resident's clear communication of this goal, the comprehensive care plan indicated long-term placement at the facility, with no evidence of quarterly updates or agreement from the resident on this plan. Interviews with facility staff, including the Nursing Home Administrator and the Director of Nursing, confirmed the absence of documented discharge plans that aligned with the residents' goals.
Obstructions in Hallways Create Safety Hazards
Penalty
Summary
The facility failed to maintain an environment free of accident hazards in three resident hallways, as observed during a survey. In the 200 hallway, three linen carts and a floor cleaning machine were positioned in a manner that obstructed access to handrails, which are essential for resident safety. Additionally, four linen carts were lined up against the wall in the hallway connecting the 100 and 200 hallways, further blocking the handrails. This area is significant as it includes access to the resident dining room, a high-traffic area for residents. In the 100 resident hallway, plastic storage bins containing PPE and a mechanical lift were placed in front of resident rooms, restricting access to handrails. Similarly, in the 200 hallway, additional PPE storage bins and two wheelchairs were found obstructing the handrails. The 300 hallway also had a plastic storage bin impeding access to handrails. The Nursing Home Administrator confirmed these observations, acknowledging that the placement of these items created obstructions, thus failing to ensure safe passage for residents, staff, and visitors.
Unsafe Oxygen Storage in Hallway
Penalty
Summary
The facility failed to store oxygen in a safe and secure manner, as observed during a survey. Seven full oxygen cylinders were found in a multi-tank rack on wheels, not secured to the wall or floor, positioned on the right side of the hallway. Additionally, five empty oxygen tanks were stored in a similar unsecured rack on the left side of the hallway near the exit door. Signs were posted above the tanks to designate areas for full and empty cylinders, but the storage did not comply with the facility's policy, which requires oxygen to be stored in an enclosed, secured area. Employee 1, a Maintenance Assistant, was observed refilling the oxygen storage rack with full tanks, resulting in a total of 12 full oxygen tanks stored in the unsecured hallway location. During an interview, Employee 1 stated that an enclosed, locked oxygen storage area is available outside the west hallway exit door, but he chose to store the tanks inside for the convenience of the nursing staff. The Nursing Home Administrator confirmed that storing oxygen in the hallway was not in accordance with the facility's policy.
Pharmacy Service Delays in Medication Administration
Penalty
Summary
The facility failed to ensure the timely provision of pharmacy services, resulting in delays in the administration of physician-prescribed medications for three residents. Resident 90, who was admitted with chronic obstructive pulmonary disease, dysphagia, depression, and anxiety, did not receive Clonazepam as prescribed due to a delay in pharmacy delivery. The Director of Nursing confirmed that the medication was unavailable at the facility at the time it was needed. Resident 64, admitted with dementia and congestive heart failure, experienced a fall and was hospitalized with fractures. Upon readmission, the resident had orders for Oxycodone for pain management, but the medication was not administered for several days due to unavailability. The resident exhibited increased confusion and pain, and Tylenol was given instead. The facility's emergency supply did not include Oxycodone, and the Director of Nursing confirmed the medication was not available since the resident's discharge from the hospital. Resident 201, admitted for aftercare and therapy, did not receive Diltiazem, Oxycodone-Acetaminophen, and Levothyroxine due to pharmacy delays. The facility's emergency medication supply and automated dispensing system had discrepancies in medication inventory and expiration dates. The Director of Nursing and Nursing Home Administrator acknowledged the lack of a backup emergency pharmacy and confirmed that nursing staff, rather than trained pharmacy personnel, were responsible for restocking the system without proper training. The facility failed to provide documentation of pharmacy oversight or staff training, leading to delays in essential medication administration.
Failure in Automated Medication System Management
Penalty
Summary
The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring proper oversight and management of its automated medication system as required by Pennsylvania Code Title 49, Chapter 27. The facility did not maintain pharmacist supervision, conduct necessary system inspections, or ensure proper medication accountability. This lack of oversight led to multiple instances of missed medication doses for residents, including Clonazepam for one resident, Oxycodone for another, and Diltiazem, Levothyroxine, and Oxycodone-Acetaminophen for a third resident. The facility also failed to maintain a readily retrievable audit trail and documented oversight of the automated medication system. The Pennsylvania code requires that automated medication systems be managed under the supervision of a pharmacist and include documentation of oversight activities, system inspections, and accountability for stocking and removing medications. However, the facility was unable to provide documentation verifying that the required oversight and management of the automated medication system were conducted. The Nursing Home Administrator confirmed that the facility pharmacy did not adhere to the Pennsylvania code regarding pharmacy services, and that pharmacy staff were not actively managing the system, contributing to medication availability issues and delays in administration.
Inaccurate MDS Assessment for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure that the Minimum Data Set Assessment (MDS) accurately reflected the status of a resident, identified as Resident 25. This deficiency was identified during a review of clinical records and the Resident Assessment Instrument (RAI), as well as through staff interviews. Resident 25 was admitted with diagnoses including dementia and oropharyngeal dysphagia. The resident had a physician order for Nutren 1.5 via a PEG tube for enteral feeding and a full liquid nectar/mildly thick consistency diet for pleasure feeding. However, the quarterly MDS assessment inaccurately indicated that the resident did not have a feeding tube. The inaccuracy in the MDS assessment was confirmed during an interview with the director of nursing. This discrepancy highlights a failure in the facility's assessment process, as the MDS did not accurately capture the resident's nutritional approaches, specifically the use of a feeding tube. The failure to accurately document the resident's status in the MDS could potentially impact the planning and delivery of appropriate care for the resident.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with newly evident serious mental disorder for a Preadmission Screening and Resident Review (PASRR) Level II evaluation. The resident, who was admitted with diagnoses including anxiety and depression, initially screened negative for serious mental illness on the PASRR Level I form. However, a nurse's note later documented that the resident expressed suicidal thoughts and was subsequently transferred to a hospital for psychiatric evaluation. Despite this significant change in the resident's mental health condition, the facility did not report the inpatient stay for suicidal ideation to the state's mental health authority for a PASRR Level II evaluation. The deficiency was confirmed during interviews with the consultant social worker and the Nursing Home Administrator, who acknowledged the facility's responsibility to ensure residents with newly evident serious mental disorders are referred for PASRR Level II evaluations. The failure to report and refer the resident for further evaluation after the hospital stay indicates a lapse in the facility's compliance with federal and state requirements for the PASRR process.
Failure to Update Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to reflect the resident's current needs and services. The resident, who was admitted with diagnoses including depression and anxiety, expressed suicidal thoughts and was transferred to the hospital for psychiatric evaluation. Despite being readmitted to the facility with a diagnosis of suicidal ideation, the care plan was not updated to address these issues. On a later date, the resident was found with self-inflicted lacerations and admitted to using a knife, which was found at the bedside. The care plan, which had not been revised since several months prior, did not include updated interventions to address the resident's suicidal statements and self-harming behavior. The Director of Nursing confirmed that the facility did not review and revise the care plan to accurately reflect the resident's current status, risks, and needs.
Failure to Implement Restorative Ambulation Program
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for a resident, identified as Resident 85. The facility's Restorative Nursing Services Policy, last reviewed in January 2025, outlines that a restorative nursing program should assist residents in achieving or maintaining their optimal functional level. However, upon review, it was found that Resident 85, who was admitted with diagnoses including diabetes and congestive heart failure, was not placed on a restorative ambulation program as recommended by therapy. The resident, who was moderately cognitively impaired, expressed a desire to walk more frequently with assistance, noting that she felt weaker when not engaged in regular walking activities. The clinical record review revealed that Resident 85 was discharged from physical therapy on February 28, 2025, with a recommendation for a restorative ambulation program to maintain her current level of functioning. Despite this recommendation, there was no evidence in the resident's care plan or clinical record that such a program was implemented. An interview with the director of nursing confirmed the lack of documented evidence for the implementation of the restorative ambulation program, which was necessary to maintain the resident's mobility as recommended by therapy.
Failure to Provide Therapeutic Social Services
Penalty
Summary
The facility failed to provide necessary therapeutic social services to two residents, leading to deficiencies in their mental and psychosocial well-being. Resident 251, who was admitted with diagnoses including alcoholism and a history of suicidal ideations, expressed a strong desire to be discharged home, which was opposed by his wife. Despite the resident's frequent expressions of frustration and agitation about wanting to leave, there was no documented evidence that social services addressed the conflict regarding discharge planning. The resident's care plan lacked interventions related to his alcoholism, suicidal ideations, or concerns about discharge planning, and there was no documentation of therapeutic social services provided to support him. Eventually, the resident signed out Against Medical Advice. Resident 81, admitted with anxiety and depression, had a documented history of suicidal ideation and self-harming behaviors, resulting in multiple hospitalizations for psychiatric evaluation. Despite these ongoing concerns, there was no evidence that the facility's social services provided appropriate therapeutic interventions to address the resident's mental health needs. A social services note mentioned the possibility of transferring the resident to another facility, but there was no documentation of any actions taken regarding alternate placement options. The Director of Nursing confirmed the lack of documented social services interventions to support Resident 81's psychosocial well-being.
Failure to Offer Routine Dental Services to Residents
Penalty
Summary
The facility failed to offer routine annual dental services to two private payor source residents, identified as Residents 60 and 39, out of four residents sampled for dental services. Resident 60, admitted with Alzheimer's disease and COPD, was severely cognitively impaired according to the Minimum Data Set assessment. There was no documented evidence that Resident 60's responsible party was offered routine annual dental services in the past year. Similarly, Resident 39, admitted with Alzheimer's disease and muscle weakness, also had no documented evidence of being offered routine annual dental services. An interview with the Director of Nursing confirmed that the responsible parties for both residents had not been consulted regarding dental services in the past year.
Failure to Offer Routine Dental Services to a Resident
Penalty
Summary
The facility failed to offer routine annual dental services to a Medicaid payor source resident, identified as Resident 64, who was admitted with diagnoses including dementia and congestive heart failure. The resident's Annual Minimum Data Set assessment indicated moderate cognitive impairment. Upon review of the clinical record, there was no documented evidence that the resident's responsible party was offered dental services in the past year. This was confirmed during an interview with the Director of Nursing, who acknowledged that the responsible party had not been consulted regarding dental services for the resident.
Lack of Coordination in Hospice Services for Residents
Penalty
Summary
The facility failed to ensure proper coordination of hospice services with facility services for two residents receiving hospice care. Resident 54, who was admitted with a diagnosis of cerebral infarct, was enrolled in hospice services for the management of this terminal illness. However, a review of the resident's plan of care revealed no evidence of integration with hospice services to demonstrate coordination of care and services to meet the resident's needs related to their terminal illness on a daily basis. Similarly, Resident 61, admitted with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and anxiety, was receiving hospice services for end-stage COPD. The review of this resident's care plan also showed a lack of coordination between the facility and the hospice agency in addressing the resident's daily care needs and specific needs related to their terminal diagnosis. The Director of Nursing confirmed that the care plans for both residents were not integrated or coordinated with hospice services, indicating a deficiency in the facility's management of hospice care coordination.
Failure to Address Resident Complaints
Penalty
Summary
The facility failed to address and resolve resident complaints and grievances in a timely manner, as evidenced by the review of the facility's policy, meeting minutes, and resident and staff interviews. Residents expressed concerns about cold shower water temperatures and the lack of evening snacks during Resident Council and Food Committee meetings from December 2023 through March 2024. Despite these repeated complaints, the facility did not provide documented evidence that they had resolved these issues or followed up with the residents to ensure their concerns were addressed. During a group meeting on April 10, 2024, four alert and oriented residents confirmed that the issues with cold shower water temperatures and the absence of evening snacks persisted. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide documentation showing that the facility had taken effective measures to resolve these complaints. This failure to address resident grievances violated the residents' rights and the facility's own grievance policy.
Failure to Provide Scheduled Showers and Personal Grooming
Penalty
Summary
The facility failed to ensure that dependent residents were provided with the necessary services to maintain good personal hygiene, specifically by not providing showers as scheduled and neglecting personal grooming for three of 23 residents sampled. Resident 7, who has multiple sclerosis and requires extensive assistance with ADLs, did not receive a shower for three months, and there was no documentation of any refusals or reasons for this. The resident was observed with long, dirty fingernails, oily hair, and an unshaven face, indicating a lack of personal grooming. Resident 47, who requires substantial assistance with ADLs and is cognitively intact, was only showered twice in three months and given a bed bath five times, with no documented evidence of refusals or reasons for not showering as scheduled. Resident 5, who has severe cognitive impairment and requires extensive assistance with ADLs, was only showered twice in two months, with no documentation of refusals or reasons for this. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility has not been able to consistently provide residents' showers as scheduled. The facility's policy requires that if a resident refuses a shower, a bed bath should be offered and provided as per the resident's preference, but there was no evidence of this being done. The DON and NHA acknowledged that it is the facility's responsibility to assist residents with activities of daily living to maintain good personal grooming and hygiene for residents dependent on staff for assistance.
Obstructed Hallways and Unlocked Treatment Cart
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards on the East and [NAME] Hallways. Observations on April 9 and April 10, 2024, revealed that the 100 East hallway was obstructed by 3 rollator walkers, 5 wheelchairs, a resident room armchair, a stool, and a large linen cart, blocking access to the handrails on the right side of the corridor. Multiple residents were observed self-propelling in wheelchairs in the hallway. The Nursing Home Administrator confirmed that the handrails were obstructed, impeding residents' access to assist with ambulation and mobility. Additionally, on April 10, 2024, a treatment cart labeled [NAME] was found unattended and unlocked in the main hallway, containing wound care equipment including scissors and hydrogen peroxide. The Director of Nursing confirmed that the cart should have been locked to prevent resident access, creating a potential accident hazard.
Failure to Administer Oxygen as Ordered and Maintain Sanitary Equipment
Penalty
Summary
The facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for Resident 47. The resident was observed receiving humidified oxygen therapy at 4 liters per minute (L/min) via nasal cannula, contrary to the physician's order of 3 L/min. Additionally, the oxygen setup, including the nasal cannula tubing and humidification bottle, was not dated. The resident's CPAP mask was improperly stored in a nightstand drawer and on top of a box containing food, rather than on a clean surface or in a bag as per facility policy. Furthermore, the nasal cannula was found on the floor and was re-applied to the resident's face without being cleaned or changed, and the oxygen concentrator was set at 4 L/min instead of the prescribed 3 L/min. Another observation revealed undated oxygen equipment in a room occupied by other residents, which was confirmed to be from a discharged resident and not removed from the room. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the physician's order for supplemental oxygen was not followed for Resident 47 and that oxygen equipment should be kept clean, stored properly, and dated when changed. The DON also confirmed that masks and nasal cannula/CPAP equipment should be placed in a bag when not in use. The facility's failure to adhere to these protocols resulted in deficiencies in the administration and maintenance of respiratory care for Resident 47.
Failure to Maintain Sanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the food and nutrition services department, several sanitation concerns were observed. These included a thick layer of dust on the fins of the wall vent next to the handwashing sink, a build-up of dirt and debris on the perimeter area of the floor throughout the kitchen, and two missing floor tiles in the walk-in refrigerator. Additionally, the door of the walk-in freezer did not fully latch, and there were multiple brownish/blackish colored splatters on the ceiling in the dishroom. A missing tile from the floor molding at the entrance to the dishroom and a build-up of a blackish substance on the wall behind the garbage disposal were also noted. Two wooden utility carts in the kitchen area were visibly soiled and in need of cleaning. Interviews with the foodservice director confirmed that the food and nutrition services department is expected to maintain acceptable practices for food storage and sanitation. The foodservice director acknowledged that the door of the walk-in freezer had not been consistently latching for a few weeks and that a work order for repair had been completed. The administrator confirmed that a new walk-in freezer door was needed and that the order was in process, with an estimated lead time of six to eight weeks for replacement. These deficiencies indicate a failure to adhere to food safety and inspection standards, potentially leading to contamination and microbial growth in food.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced a significant decline in condition and was placed on hospice care. The resident was enrolled in hospice care on January 13, 2023, and later discontinued from hospice services on February 25, 2024. Despite these significant changes in the resident's condition, there was no documented evidence that a significant change MDS assessment was completed as required by federal regulations. An interview with the Director of Nursing (DON) confirmed that the resident was discontinued from hospice services on February 25, 2024, and that a comprehensive significant change MDS assessment was not completed. This failure to conduct the required assessment was identified during a review of the clinical record and the Resident Assessment Instrument (RAI) User's Manual, which mandates that a significant change MDS assessment be conducted within 14 days of the determination of a significant change in the resident's condition.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the annual MDS Assessment for a resident dated June 23, 2023, incorrectly indicated that the resident did not require a Level II Preadmission Screening and Resident Review (PASRR) process. However, a review of the resident's clinical record revealed that a Level I PASRR completed on June 1, 2017, indicated the resident met the criteria for a Level II PASRR. Additionally, a letter of determination dated June 8, 2017, confirmed the resident required specialized services. This discrepancy was confirmed by the social services director during an interview on April 12, 2024.
Failure to Update Care Plan After Discontinuation of Hospice Services
Penalty
Summary
The facility failed to revise and update the comprehensive care plan for a resident after the discontinuation of Hospice services. The resident, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and was receiving Hospice services due to end-stage COPD, had their Hospice services discontinued. Despite this significant change in the resident's care needs, the facility did not update the care plan to reflect the discontinuation of Hospice services. This failure was confirmed during an interview with the director of nursing, who acknowledged that the care plan had not been reviewed and revised to ensure appropriate interventions were incorporated and implemented by the staff.
Failure to Develop Individualized Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms. Resident 34, who was admitted with a diagnosis of dementia with agitation, exhibited severe cognitive impairment and displayed physical and verbal behavioral symptoms such as hitting, kicking, pushing, scratching, threatening, screaming, and cursing. Despite these behaviors being documented in the resident's clinical record and progress notes, the resident's care plan did not identify specific behaviors or interventions designed for staff to address these behaviors. The facility did not provide evidence of individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests. There was no indication that the facility provided necessary care and services, including interdisciplinary non-pharmacological approaches, purposeful and meaningful activities, or specialized services and supports such as specialized activities, nutrition, and environmental modifications. An interview with the Nursing Home Administrator confirmed the lack of an individualized person-centered plan for managing the resident's dementia-related behaviors.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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