Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of East Mountain during CMS and state inspections, most recent first.
A resident with hydrocephalus and weakness reported mouth pain for months, but dental care was delayed despite repeated complaints to staff. The dentist initially evaluated the resident and planned extractions, but the procedure was postponed because consent was not obtained in time, and the resident was not scheduled for the next dental visit. The facility’s policy required assistance with routine and emergency ancillary services, including urgent dental treatment for pain.
A resident with mild intellectual disability and moderate cognitive impairment was not identified as an elopement risk in the care plan or available assessment records. The resident exited through an unlocked, unmonitored lobby door without staff awareness, walked home in winter conditions, and the facility did not realize the resident was missing until the guardian notified the DON. The report also notes the facility had no receptionist to monitor the lobby or main entrance and lacked a system to track resident whereabouts in common areas.
Failure to Resolve Resident Grievances and Keep Residents Informed: The facility did not promptly address or document resolution of resident complaints raised in RC meetings and verbal grievances. Residents reported concerns about lack of evening snacks, shower temperatures, and reduced activities, and stated they had filed grievances with no follow-up. Surveyors found the grievances were missing from the grievance list, later provided forms had the resolution section cut off, and the DON and DOSS could not show that the concerns had been addressed.
A facility failed to maintain effective administrative oversight and resident supervision to prevent elopement. A resident exited through an unlocked, unmonitored lobby door without staff awareness and was missing for more than two hours before nursing staff learned of the absence from the resident's legal guardian. The facility had eliminated the receptionist position and did not put another system in place to monitor the front entrance, and the report states that effective supervisory systems were not demonstrated for other residents at risk for elopement.
Unsafe and Unclean Resident Shower Rooms: Residents reported that two shower rooms were frequently cold and that hot water in one room intermittently turned cold during showers, with staff aware but no action taken. Surveyors also found 42 missed water temp log entries, a 65-degree shower room with a urine odor, loose/missing tiles, and black buildup around drains and baseboards; the maintenance director acknowledged unresolved heating issues affecting the shower area.
Failure to provide an ongoing activities program: residents reported no meaningful activities aligned with their interests, and scheduled coffee socials and puzzles did not occur. The Resident Council President said activity staff had resigned or left, and the DON confirmed the facility had no structured activities program, with no activities conducted by activity staff and no evening activities in place.
The facility failed to maintain a qualified activities director. After the prior Activities Director left, the DON and Regional Nurse Consultant confirmed there was no activities director in place, and the newly hired individual did not meet the minimum qualifications. The NHA confirmed the person was not licensed, registered, or eligible for certification as a therapeutic recreation specialist, was not an activities professional recognized by an accrediting body, and lacked the required experience in a social or recreational program.
Inconsistent Evening and Bedtime Snack Service: Residents reported that evening and bedtime snacks were no longer being passed after a decrease in activities staffing, and the prior snack distribution process had stopped for about three weeks. An observation of the resident pantry found only two open boxes of snack items available for the unit, while the DON confirmed no new process had been established to ensure residents consistently received a nourishing bedtime snack as desired.
Oxygen Therapy Not Administered Per Order: A resident with peripheral vascular disease had an order for O2 at 2 L/min via NC for SOB, but surveyors observed the concentrator set at 0.5 L/min while the resident was awake in bed and not in distress. An LPN confirmed the resident should have been receiving continuous oxygen at 2 L/min, and the DON and Regional Nurse Consultant acknowledged the facility was responsible for ensuring oxygen was given per provider orders and professional standards.
A resident with a suprapubic catheter had a urology consult that recommended monthly catheter changes and monthly clinic visits if the facility could not safely remove and reinsert the catheter, but the record lacked evidence that the MD reviewed or acted on those recommendations. Nursing notes later documented repeated catheter blockages with unsuccessful flushing attempts and removal/reinsertion of the catheter, and the DON could not show provider oversight of the consult.
An LPN and an RN were observed with multi-dose medication vials in two medication rooms that were in use but not labeled with an open date. One vial of Tuberculin PPD and one vial of Lantus insulin were stored in medication refrigerators without dates showing when they were first opened, and the DON confirmed the facility failed to ensure the vials were dated in accordance with policy and manufacturer instructions.
Failure to Provide Written Transfer Notices and Ombudsman Copies: The facility did not document that two residents and their representatives were notified in writing, in a language and manner they understood, of facility-initiated hospital transfers. The facility also could not show that copies of the transfer notices were sent to the Office of the State LTC Ombudsman, and the NHA confirmed the missing documentation.
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.
Delayed Dental Care and Consent Process
Penalty
Summary
The facility failed to ensure timely and necessary dental services for a Medicaid resident who was cognitively intact and had diagnoses including hydrocephalus and weakness. The resident reported mouth pain to staff for months and stated that she first complained of pain in the beginning of March, but she did not see the dentist until the tooth was extracted on April 30, 2026. The facility policy stated that it was to assist residents in obtaining routine and emergency ancillary services as needed, and defined emergency dental services as treatment for pain in teeth, gums, broken or damaged teeth, or any other problem requiring immediate attention by a dentist. An email from the social services director requested a dental evaluation after the resident complained of tooth pain, and the dental services coordinator responded that the resident would be seen 10 days later. At that visit, the dentist noted that the resident requested extraction of two teeth with plus 2 mobility and planned to extract them at the next visit. The dental care coordinator later requested a consent form before scheduling the extraction, and when the social services director asked how consent would be obtained if the resident could not physically sign, the coordinator confirmed verbal consent was acceptable. The resident was not on the schedule for the next dental visit because consent had not been obtained, and the extraction was not scheduled until later after the consent was eventually sent.
Failure to Supervise Resident and Identify Unsupervised Exit
Penalty
Summary
The facility failed to provide adequate supervision to monitor the whereabouts of Resident 26 and to promptly identify the resident’s absence from the facility. Resident 26 was admitted with a diagnosis of mild intellectual disability and had independent ambulation. A quarterly MDS dated November 22, 2025, showed a BIMS score of 11, indicating moderate cognitive impairment. The resident’s care plan, initiated April 4, 2025, did not identify the resident as an elopement risk, and the initial elopement risk assessment requested by surveyors was not provided and was not located in the electronic medical record. On December 22, 2025, Resident 26 was last seen in the main lobby requesting staff assistance to make telephone calls to her guardian. Facility surveillance video showed the resident exiting through the lobby door at 11:03 AM without staff awareness. The resident returned to the facility at 1:06 PM by a neighbor’s private vehicle after having walked to her home, located two to three miles from the facility, during winter weather with a temperature of 30 degrees Fahrenheit and in an area of heavy vehicular traffic. Upon return, nursing documentation noted the resident was wearing a coat, hoodie, pants, and sneakers, had a body temperature of 97.2 degrees Fahrenheit, and had an open area on the left great toe measuring 2 cm by 2 cm by 0.1 cm with a small amount of serous drainage and an epithelialized base. The facility was not aware the resident had left until notified by the legal guardian, who reported receiving a call from the resident at 10:32 AM stating she wanted to leave the facility and go home. At that time, licensed nursing staff were unaware the resident was not at the facility. Review of witness statements showed conflicting last-seen information, including that the resident was observed in the lobby at 10:30 AM and also walking toward the dining room with her father, who was another resident. The facility had eliminated the receptionist position, leaving no staff assigned to monitor the front lobby or main entrance, and the report states the facility permitted access to an unlocked and unmonitored exit and lacked a system to account for resident whereabouts in common areas such as the lobby.
Failure to Resolve Resident Grievances and Keep Residents Informed
Penalty
Summary
The facility failed to honor residents’ rights to organize and participate in resident and family groups by not promptly resolving continued complaints and grievances raised during Resident Council meetings and verbal reports. Facility policy stated that residents, families, and representatives had the right to voice grievances and that the grievance official would keep the resident apprised of progress toward resolution, but survey review found no documented evidence that concerns raised in Resident Council minutes were addressed or that residents were kept informed of grievance status. Resident Council minutes from a food committee review documented complaints that evening snacks were not being provided, yet no grievance or corrective documentation was found for that concern. During a group meeting with five residents, multiple concerns were voiced about potential new ownership, significant facility changes since December 2025, lack of activities, shower temperatures on both halls, and inability to obtain snacks after dinner. The residents stated they had filed grievances after the prior Resident Council meeting and reported no follow-up. The grievances were not included on the facility’s December grievance list, and when later provided, they had been altered with the bottom portion cut off so no resolution was documented. The Director of Social Services stated she had been told by the former NHA to cut off the portion documenting resolution and could not provide evidence the grievances had been addressed; the DON also confirmed there was no documented action addressing the grievances.
Failure to Monitor Lobby Exit and Resident Elopement
Penalty
Summary
The facility failed to ensure effective administrative oversight to maintain systems necessary to provide a safe environment and adequate supervision to prevent resident elopement. The report states that the Nursing Home Administrator and Director of Nursing had defined responsibilities for overseeing daily operations, resident safety, staffing, policies, and supervision, but the facility did not have effective systems in place to monitor resident whereabouts, supervise common areas, or promptly identify and respond to a missing resident. The facility had eliminated the receptionist position and did not implement an alternative system to monitor the front lobby and main entrance, leaving an unmonitored point of exit. Resident 26 exited the facility through an unlocked and unmonitored lobby door without staff awareness and remained absent for more than two hours. Licensed nursing staff did not know the resident was missing until the resident's legal guardian notified them. The investigation also found that, after the elopement, the facility did not demonstrate that effective supervisory systems had been implemented to identify and mitigate elopement risks for other residents. The report states that this resulted in Immediate Jeopardy to Resident 26 and placed eight residents at risk.
Unsafe and Unclean Resident Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment in two resident shower rooms, identified as the East shower room and another shower room. During a resident council meeting, five cognitively intact residents reported that throughout December and up to the survey period, the East shower room was frequently cold and uncomfortable, and the other shower room’s hot water intermittently turned cold during showers. The residents stated nursing staff were aware of the problem, but nothing had been addressed. A nurse aide also reported that showers could be completed in the other shower room, but the water temperature became colder with increased use, and when the water was not comfortable, staff used the East shower room instead. Survey observations and records supported these concerns. The facility’s daily water temperature logs for both shower rooms showed multiple missed recordings across December and early January, totaling 42 missed observations. During an observation of the East shower room with the maintenance director, the room temperature was 65 degrees Fahrenheit and felt uncomfortably cold. The room also had a strong urine odor, missing or loose tiles along the baseboard, and a buildup of a black substance in the corners and crevices around the drains and baseboard. A work order from early December documented the East shower room temperature at 68 degrees Fahrenheit. The maintenance director stated he had identified maintenance issues throughout the facility, including the heating system serving the East shower room, but had not yet repaired it. The interim NHA confirmed the shower rooms should be maintained to assure comfortable temperatures and a clean area for a homelike environment.
Failure to Provide Scheduled Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet residents’ interests and support their physical, mental, and psychosocial well-being. During a resident group interview, five residents stated there were no meaningful activities being offered that aligned with their interests. The Resident Council President reported that all activity staff had resigned or were no longer employed by the facility, and residents described frustration and disappointment with the lack of activities and the departure of the former Activity Director, whom they said had provided enjoyable activities. The January 2026 activity calendar listed activities that did not occur, including a coffee social and puzzles on January 6 and a coffee social on January 7. No documentation was provided showing alternative activities were offered in place of the missed events. The DON stated the facility previously had four activity staff members, but the Activity Director resigned on December 31, 2025, and the last remaining activity aide’s final day was January 2, 2026. The DON confirmed no activities had been conducted by activity staff from January 2, 2026, through the interview date, and acknowledged the facility was not currently offering a structured activities program, including evening activities.
Unqualified Activities Director
Penalty
Summary
The facility failed to employ and maintain a qualified activities director. Facility documentation showed the Activity Director job description required the position to plan, organize, develop, direct, and implement the overall operation of the Activity Department in accordance with federal, state, and local standards and to assure an ongoing program of activities designed to meet each resident’s interests and physical, mental, and psychosocial well-being. During interviews with the DON and Regional Nurse Consultant, it was reported that the Activities Director left employment and that since that departure there had been no activities director in place. The facility had hired an individual to serve as activities director, but review of the application showed no experience or qualification as an activity director. The NHA confirmed the newly hired individual did not meet the minimal qualifications, was not licensed, registered, or eligible for certification as a therapeutic recreation specialist, was not an activities professional recognized by an accrediting body, and did not have two years of experience in a social or recreational program within the last five years.
Inconsistent Evening and Bedtime Snack Service
Penalty
Summary
The facility failed to consistently provide evening and bedtime snacks in accordance with residents’ needs, preferences, and requests. During a resident group interview, five cognitively intact residents reported that since a decrease in activity department staffing, evening/bedtime snacks were no longer being passed to residents, although they wanted to receive them. The residents stated that, before the staffing decrease, after-dinner activities staff would obtain snacks from dietary and distribute them to each unit based on resident preference, but that this process had not occurred for about three weeks. An observation of the resident pantry showed only two open boxes of oatmeal cream pies and cookies available for residents, which was not enough for all residents on the unit. The resident refrigerator/freezer contained items brought in from outside the facility for specific residents, pitchers of fruit punch and lemonade, and applesauce for medication passes. The DON confirmed that activities staff were responsible for distributing evening/bedtime snacks, but no new process had been established or assigned to another staff member or department after the decrease in activities staffing. The DON also confirmed that residents were not consistently receiving snacks as desired and should receive a nourishing snack at bedtime on a daily basis.
Oxygen Therapy Not Administered Per Order
Penalty
Summary
The facility failed to ensure oxygen therapy was administered according to physician orders and consistent with professional standards of practice for one resident. The facility policy titled Oxygen Administration states oxygen is to be provided to residents who need it under physician orders, except in an emergency, and identifies physicians, RNs, LPNs, and respiratory therapists as personnel authorized to initiate oxygen therapy. Resident 40 was admitted with diagnoses including peripheral vascular disease. The resident had a provider order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. During observation, the resident was awake in bed with the head of bed elevated and oxygen in place via concentrator, but the liter flow was set at 0.5 liters per minute rather than the ordered 2 liters per minute. The resident was not in distress and was breathing easily. An LPN confirmed the resident should have been receiving continuous oxygen via nasal cannula at 2 liters per minute, and the DON and Regional Nurse Consultant confirmed it was the facility's responsibility to ensure oxygen therapy was administered per provider orders and professional standards of practice.
Failure to Obtain Physician Review of Urology Consult for Suprapubic Catheter
Penalty
Summary
The facility failed to ensure physician review and oversight of recommendations from a consulting urology specialist for Resident 11. Resident 11 was admitted with a diagnosis of permanent atrial fibrillation and was hospitalized from February 13, 2025, to February 22, 2025, for sepsis. During that hospitalization, a urology consult dated February 17, 2025, recommended placement of a suprapubic catheter due to urethral pathology, and the catheter was inserted before the resident returned to the facility with it in place on February 22, 2025. The care plan initiated February 23, 2025, identified that the resident had a suprapubic catheter and included a goal for the resident to remain free from catheter-related trauma. At a urology appointment on May 9, 2025, the suprapubic catheter was replaced, and the written consult recommended that the skilled nursing facility change the catheter monthly; it also stated the resident would require monthly clinic visits if the facility was unable to safely remove and reinsert the catheter. The facility record did not show that these recommendations were reviewed, acknowledged, or verified by the facility physician, and there was no physician progress note, order, or other documentation showing provider review of the catheter change schedule. Nursing documentation later showed repeated episodes of suprapubic catheter blockage on November 11, November 30, December 16, December 23, January 2, and January 6, with the catheter documented as not draining, unsuccessful flushing attempts, and removal and reinsertion of the catheter. During interview, the DON was unable to provide evidence that the facility medical provider reviewed or acted on the May 9 urology consult.
Multi-dose medication vials were left undated in two medication rooms
Penalty
Summary
The facility failed to ensure that multi-dose medication vials were labeled with an open date in two medication rooms, including the East Hall Medication Room and the [NAME] Hall Medication Room. A review of the facility policy titled Medication Administration and Medication Storage stated that medications and biologicals are to be stored safely and in accordance with manufacturer or supplier instructions, and that multi-dose vials must be dated when first opened or accessed and discarded within 28 days unless the manufacturer specifies otherwise. During an observation of the [NAME] Hall Medication Room medication refrigerator, a vial of Tuberculin Purified Protein Derivative was found stored for resident use without a label showing the date it was opened. An LPN confirmed the vial had been opened and was in use but was not dated. A second observation in the East Hall Medication Room found a vial of Lantus Insulin Glargine stored in the medication refrigerator and available for resident use without an open date. An RN confirmed that the insulin vial had been opened and was in use but was not dated. The DON later confirmed that the facility failed to ensure multi-dose medication vials in both medication rooms were labeled with the date opened, preventing staff from determining whether the medications were within the manufacturer’s recommended time frame for safe use.
Failure to Provide Written Transfer Notices and Ombudsman Copies
Penalty
Summary
The facility failed to notify the resident and the resident's representative(s) in writing, in a language and manner they understand, of facility-initiated hospital transfers and failed to provide copies of the written transfer notices to a representative of the Office of the State Long-Term Care Ombudsman for two residents reviewed. Resident 11 was admitted to the facility on [DATE], transferred to a community hospital on August 29, 2025, and later readmitted on [DATE]. Resident 41 was admitted to the facility on [DATE], transferred to a community hospital on December 16, 2026, and later readmitted on [DATE]. The facility was unable to provide documented evidence that either resident and their representative were notified in writing of the reasons for transfer or that copies of the transfer notices were sent to the Ombudsman representative. An interview with the Nursing Home Administrator on January 8, 2026, confirmed there was no documented evidence that copies of the transfer notices for Resident 11 and Resident 41 were sent to a representative of the Office of the State Long-Term Care Ombudsman.
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.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 481 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wilkes-barre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heinz Transitional Rehabilitation Unit | 2.5 mi | ★★★★★ | 2 | 0 |
| Wesley Village | 2.5 mi | ★★★★★ | 9 | 0 |
| Riverstreet Manor | 3.2 mi | ★★★★★ | 25 | 0 |
| Third Avenue Health & Rehab Center | 3.5 mi | ★★★★★ | 13 | 0 |
| Embassy Of Wyoming Valley | 3.6 mi | ★★★★★ | 31 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.