Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Scranton during CMS and state inspections, most recent first.
The facility failed to ensure a qualified RD provided routine on-site oversight of food and nutrition services after the long-term RD resigned. The dietary manager reported no routine clinical nutrition coverage on-site, and the NHA confirmed a remote RD covered the role off-site and also served sister facilities. Time records showed only limited off-site hours, and the corporate RD confirmed the remote RD did not routinely perform on-site oversight, staff training, direct resident observations, or meal service monitoring.
Menu substitutions were not followed, documented, or reviewed as required. A resident meal service showed planned items were omitted and replaced with different foods, and several residents said meals were often not served as posted and they were not told about menu changes. Staff confirmed some ordered items were unavailable, substitutions were not made when replacement foods were limited, and the corporate RD had no knowledge of the omissions or substitutions.
Meals were served with poor presentation and at unsafe temperatures during tray service. A cognitively intact resident reported disliked foods, missing menu items, and meals that were often visually unappetizing, while several residents said menu substitutions were frequent and not routinely communicated. A sampled tray showed hot items below the safe holding temp and ice cream that was melted and partially liquified, and taste testing found the food bland and lukewarm.
Unsafe food storage and sanitation practices were observed in the dietary dept and a second-floor resident nourishment area. Staff were seen handling food service equipment without a beard guard, a janitor's closet contained soiled rags and wet mop heads, a cooler condenser fan was corroded with ice crystals, bulk flour was stored in an ill-fitting container, and debris and dead insects were found under shelving. In the resident pantry, the freezer and refrigerator contained unlabeled, opened, and improperly stored food items, and multiple cases of food were later found stored directly on the floor in the walk-in cooler, walk-in freezer, and dry storage area.
Unclean and poorly maintained first-floor resident areas: The facility left the first floor licensed and available for resident occupancy even though the rooms were unoccupied for years, and the NHA confirmed they remained on the state license. Surveyors observed dirty floors, stained and ripped mattresses, missing privacy curtains, broken or missing outlet covers, exposed screws, damaged fixtures, missing screens, and air conditioning units or covers that were removed or left exposing the outside environment. Bathrooms had stained toilets, dirty sinks and floors, ceiling tile discoloration, and dead insects, and the dining/activity room had a missing window screen during an optometry clinic with residents waiting.
Care Plans Not Reviewed After MDS Assessments: The facility failed to review, revise, and discuss comprehensive care plans with residents or their representatives after MDS assessments for three residents. The records showed active pain and fall-risk care plans, but no evidence of care plan conferences, resident participation, or timely updates after quarterly and annual assessments. Interviews with the NHA, ADON, and RNAC confirmed the care plans were not routinely reviewed or revised as required.
Failure to Monitor Weights and Nutrition Status Two residents had significant weight loss without timely weight tracking, complete meal intake documentation, or prompt nutrition interventions. One resident with dementia and depression had an 11.8-lb loss in one week, missed meal intake charting, and a requested reweigh that was not completed. Another resident with dysphasia and HF had ordered supplements delayed, a 15.7% weight loss documented, and no ongoing nutrition monitoring after the loss was identified.
Expired medications, undated multi-dose vials, and expired specimen collection supplies were found in two medication rooms. An LPN confirmed expired IV antibiotics and Omeprazole were still available for resident use, and an RN observed opened Aplisol and Insulin Lispro vials with no open dates, along with expired Aptima swabs and viral transport devices. The NHA and Corporate DON acknowledged the medication storage and labeling failures.
A facility failed to consistently provide evening and bedtime snacks as desired by residents. Four residents reported that snacks were not routinely offered, that they had raised the issue at resident council meetings, and that nursing staff did not always deliver snacks brought up by dietary. The NHA could not explain why snacks were not consistently offered, despite a policy requiring HS snacks for all residents and nourishing snacks for diabetic residents.
A dentist conducted dental exams in a dining room with multiple residents present, while a dental assistant’s computer screen was visible and resident-specific health information was discussed aloud. No curtain, partition, or other privacy barrier separated the resident being examined from the residents waiting nearby, and the NHA acknowledged that several residents had already been examined this way.
Failure to Assess and Monitor Resident After Witnessed Fall: A resident with Alzheimer’s disease and DVT was receiving Lovenox when he had a witnessed fall in the activity room and struck a chair before landing on the floor. Nursing documentation was missing for the post-fall response, including assessments, neuro checks, pain checks, monitoring, and progress notes, and staff could not identify who responded. More than two days later, the resident’s wife noted abdominal bruising, swelling, pain, and altered mental status, and the resident was sent to the hospital where a large rectus sheath hematoma with active bleeding was found.
A resident with bipolar disorder repeatedly reported that he was waiting for prescribed glasses and could not see well without them, but no glasses were present and the record showed no documented evidence they had been ordered. An eye consult said glasses were needed and to be ordered, while psych consults noted the resident’s ongoing concern and that his depression was negatively affected by the lack of glasses; the DON had no knowledge of the glasses, and the NHA could not provide evidence of an order, an unpaid prior bill, or facility assistance.
Failure to implement ordered restorative nursing services for a resident with a right femur fracture and significant mobility impairment. PT recommended passive ROM and active assistive ROM to both lower extremities, but the restorative program was not included in the care plan and there was no documented evidence in the task records that nursing staff carried out the ordered exercises. The DON acknowledged the facility could not show the program was consistently implemented.
Unsafe Electrical Connections in Resident Rooms: A facility failed to maintain safe electrical arrangements in multiple resident rooms when a fan, bed, nebulizer, TV, tube feeding pump, CPAP machine, and electric wheelchair charger were observed plugged into chained extension cords and power strips rather than directly into wall outlets. The NHA confirmed the observations.
A resident with a PEG tube, severe cognitive impairment, and dysphagia received continuous enteral nutrition, but the record lacked clear orders for residual limits and feeding timing, and nursing documentation did not show actual intake totals. Staff observed the tube feeding disconnected for extended periods, and the resident lost 9 pounds in about 3 weeks. The RD did not address the significant weight loss until it was triggered, and the DON confirmed staff were not calculating or totaling tube feeding intake amounts.
A resident with bipolar disorder repeatedly expressed distress about not having glasses, and psychiatric notes documented worsening depression and irritability related to that unmet need. The resident also had ongoing aggressive and disruptive behaviors, but the behavior care plan had not been revised despite escalation, and staff were unable to show effective individualized behavioral health interventions beyond offering snacks; during one outburst, staff could not de-escalate the resident and police were called.
The facility failed to implement EBP for two residents with wounds. One resident had a Stage 3 sacral pressure ulcer, moderate cognitive impairment, and an EBP order, but gowns and gloves were not available in the room for high-contact care and an LPN confirmed the supplies were missing. Another resident had multiple diabetic and venous wounds, but the physician orders and care plan did not show EBP had been implemented. The ADON and NHA confirmed the facility did not follow its EBP policy.
Nonfunctioning PTAC units were found in resident care areas, including one resident room and the PT department. A resident reported her room unit had not worked for months, and the roommate preferred air conditioning because she became hot. The DOR stated four units were out of service, but the facility could not provide proof that replacement units or repair parts had been ordered, and the NHA could not show timely action had been taken.
A resident with schizophrenia, bipolar disorder, and dysphagia was admitted and readmitted multiple times without the facility completing required comprehensive admission/readmission evaluations or verifying diet orders against prior records and swallowing needs. Initial and subsequent documentation showed inconsistent diet specifications (mechanical soft with nectar thick liquids vs. mechanical soft with thin liquids), with no evidence that staff contacted the hospital or prior group home to confirm the resident’s established puree/nectar thick diet. Required sections of the RD’s nutrition evaluation regarding prior therapeutic diet and familiarity with mechanically altered diets were left blank, and an admission evaluation was not completed after one readmission, while the existing diet order remained active without reassessment. Later, an IDT conference and SLP evaluation identified oral dysphagia and confirmed the resident’s prior puree/nectar thick regimen, underscoring that earlier diet orders and assessments had not been verified or aligned with the resident’s known swallowing deficits.
A resident with bilateral lower extremity amputations and intact cognition did not have reasonable access to a call bell needed to obtain staff assistance. During observation, the call bell cord was wrapped around the bed frame and positioned behind the resident’s head, with additional restriction from bags stored behind the bed, forcing the resident to reach backward to access it. The facility’s policy requires staff to ensure call light accessibility and response, yet clutter in the room had been discussed without resolution. Resident council minutes and a grievance documented broader concerns about delayed call bell responses and difficulty obtaining toileting assistance during the night shift.
A resident with anxiety, major depressive disorder, a history of suicide attempts, and prior psychiatric hospitalizations exhibited escalating anxiety, restlessness, pacing, self-harm behaviors, and worsening depression over time, while sharing a room with a spouse who was known to be a trigger and part of prior joint suicide attempts. The care plan for depression and anxiety did not include the resident’s suicide attempt history until after a serious incident, and there is no indication that enhanced supervision or suicide precautions were implemented despite persistent high-risk symptoms and staff reports of frequent falls and worsening mood. On one shift, an RN supervisor assessed the resident for nausea and urinary complaints, left the room after the resident became verbally abusive and returned to bed, and shortly thereafter the resident, alone with the spouse, opened an unsecured second-floor window that lacked any limiting device and jumped out. Facility investigation and maintenance interviews showed that windows were not routinely inspected, that some windows had rubber stoppers limiting opening while others had none, and that the resident’s window and other windows accessible to residents could open fully without restriction, demonstrating a systemic failure to control environmental hazards and prevent accidents or self-harm.
A resident admitted from a hospital with anxiety and depression did not receive the hospital-recommended psychotropic medication regimen. Despite documentation that Fluoxetine had been increased to 60 mg daily during a recent psychiatric stay, the facility’s CRNP ordered only 20 mg daily at admission, later increased it to 40 mg, and did not implement the 60 mg dose for several weeks. Lorazepam 0.5 mg twice daily was continued and then discontinued without a documented gradual dose reduction, contrary to hospital psychiatric recommendations. Facility policies required timely chart review and appropriate psychotropic management, but the DON could not provide justification for the deviations from the prescribed regimen.
Facility leadership, including the NHA and DON, did not effectively manage operations to ensure resident safety, failing to maintain an environment free of accident hazards, to provide adequate supervision, and to consistently implement safety policies. Windows were not secured to reduce environmental hazards, and additional unsecured windows remained in the facility. For a resident with psychiatric conditions, including suicidal ideation and worsening depression, the facility did not ensure appropriate oversight of psychiatric treatment and medication management, including correct dosing, timing, and monitoring for effectiveness and side effects. These failures allowed the resident to exit through a second-floor window and land on a porch in the snow, resulting in an Immediate Jeopardy citation under F689.
Call Bell Not Accessible to Resident: A resident with bilateral lower-extremity amputations and intact cognition was found unable to reach the call bell because the cord was wrapped around the bed frame and positioned behind the resident’s head, with bags behind the bed limiting the cord length. The resident could not explain how it was placed there. Resident council minutes also reflected concerns about call bell response times, and a grievance about call bell response concerns remained unresolved.
Several residents did not consistently receive fresh ice water due to a broken ice machine and inconsistent staff practices, leading to residents making their own ice and storing water in freezers. Staff confirmed the lack of fresh water provision during some shifts, and unsanitary conditions were observed in ice chests, with stagnant water and debris present.
Surveyors identified unsanitary conditions in the dietary department and resident pantries, including dirty dishwashing areas, soiled food containers, stagnant water with insects in ice chests, and unlabeled or expired food items. Staff interviews revealed a lack of awareness about proper food storage, and multiple food items were found without required labeling or dating, with strong odors and visible contamination present.
Multiple residents experienced excessive call bell wait times and were not provided with timely updates or written resolutions regarding their grievances. Staff interviews and observations confirmed a lack of consistent grievance tracking and follow-up, with some residents left in soiled conditions due to unaddressed care needs.
Two residents were discharged—one to the hospital after an episode of altered mental status and another home at their request—without completion of required discharge summaries or recapitulation of their stays, as confirmed by staff interviews and clinical record review.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
A resident with depressive disorder and weakness was prescribed Sertraline 25mg, and the consulting pharmacist recommended a gradual dose reduction. The attending physician did not document a response or rationale for continuing the medication, despite facility policy requiring such documentation. The DON confirmed the physician was notified but had not responded.
A resident was administered an antibiotic for a suspected UTI without meeting established clinical criteria, and the prescribed medication was later found to be ineffective against the identified bacteria. Documentation did not support the initiation of antibiotic therapy, and the DON was unable to provide further justification.
The facility did not ensure its essential ice machine was maintained in safe working order, resulting in residents not consistently receiving fresh ice water for approximately two weeks. Multiple residents reported having to purchase their own ice due to the broken machine, and a nurse aide confirmed the lack of consistent fresh water during shifts.
A resident receiving enteral tube feeding was found to have dried nutritional formula residue on the tube feeding pole, fall mat, and bedside table in their room. Multiple observations confirmed the presence of these residues, and the Nursing Home Administrator acknowledged that these areas should be kept clean and free from tube feeding spills.
A resident with bilateral leg amputations and a need for two-person assist was transferred by a single staff member who failed to lock the wheelchair, resulting in a fall onto the amputation site. The facility's investigation was incomplete, lacking key documentation and accountability, and no new interventions were implemented after repeated falls.
A resident with bilateral leg amputations and a care plan requiring two-person transfers was moved by a single staff member using a sliding board, resulting in a fall. The facility did not conduct a thorough investigation, failed to identify the staff involved, and did not implement corrective actions or analyze the incident as required by policy.
A resident with MS and dysphagia experienced significant weight loss over several weeks, but staff did not notify the physician or responsible party, nor did they conduct a timely nutritional assessment or revise the care plan. The RD confirmed that the nutritional regimen was not reviewed or changed until weeks after the weight loss, and there was no documented interdisciplinary reassessment or intervention during the decline.
A resident with PTSD, metabolic encephalopathy, and major depressive disorder did not have an individualized care plan addressing PTSD triggers or interventions to minimize re-traumatization. The facility did not demonstrate provision of trauma-informed, culturally competent care in accordance with professional standards.
A resident admitted with weakness and requiring personal assistance did not receive the required SNF-ABN notice about the end of Medicare Part A coverage until the day coverage ended. The DON confirmed the notice was not provided in advance, as required.
The facility failed to serve meals at safe and appetizing temperatures, affecting six residents. A breakfast cart was left unattended, leading to food being served within the 'Danger Zone' temperature range. Residents reported that food was often cold and unpalatable. The Nursing Home Administrator and dietary manager confirmed the deficiency.
Embassy of Scranton was found non-compliant with regulations for maintaining a safe and homelike environment. The kitchen and laundry room entrance doors were broken, unable to be properly closed or locked, posing safety and security issues. Despite receiving a repair quote in August 2024, the facility had not acted on it. The Dietary Manager and Nursing Home Administrator confirmed the disrepair during interviews.
The facility did not meet the required nurse aide to resident ratios on five shifts, with insufficient staffing on both day and night shifts. No additional higher-level staff were available to compensate for these deficiencies, as confirmed by the Nursing Home Administrator.
The facility did not meet the required LPN to resident ratios on two occasions. On the night shifts, the facility had fewer LPNs than required for the resident census, with no additional higher-level staff available to compensate. The Nursing Home Administrator confirmed the staffing shortfall.
The facility did not meet the required nurse aide to resident ratios on two occasions. On one evening shift, there were 6 nurse aides for 76 residents, below the required 6.91. On a day shift, there were 7.30 nurse aides for 75 residents, below the required 7.50. No additional staff were available to compensate for these deficiencies.
The facility did not meet the required LPN to resident ratios on one night shift, having only 1.50 LPNs instead of the required 1.88 for a census of 75 residents. This deficiency was confirmed through staffing records and an interview with the Nursing Home Administrator. No additional higher-level staff were available to address the shortfall.
The facility failed to provide timely treatment and medication administration for two residents. One resident experienced an 18-hour delay in receiving STAT intravenous fluids due to a lack of prompt notification to the physician. Another resident received multiple medications, including Apixaban and Carbidopa-Levodopa, over 60 minutes past the scheduled time, potentially compromising their effectiveness. Interviews confirmed the facility's responsibility in these deficiencies.
The facility did not meet the required nurse aide to resident ratios on two shifts. On one day shift, 8.00 NAs were provided instead of the required 8.20 for 82 residents, and on the night shift, 4.25 NAs were provided instead of the required 5.47. No additional higher-level staff were available to compensate for this deficiency, as confirmed by the DON.
The facility failed to resolve resident complaints about untimely call bell responses and inconsistent snack distribution, as repeatedly expressed during Resident Council meetings. Despite having a grievance policy, the facility did not provide evidence of addressing these issues or informing residents of resolution efforts, as confirmed by interviews with the NHA and DON.
The facility did not have a comprehensive grievance policy, failing to support residents' rights to file grievances anonymously and lacking necessary procedural information. Observations showed missing details on grievance forms' locations, anonymous filing procedures, and contact information for the grievance official. The Nursing Home Administrator and DON acknowledged these deficiencies.
A facility failed to meet professional standards of quality by improperly administering IV medication via a PICC line for a resident with sepsis and bilateral lower extremity wounds. Multiple LPNs signed the MAR for administering the medication, despite not being permitted or trained to do so. The DON confirmed a lack of ongoing education and supervision for LPNs regarding IV administration, contributing to the deficiency.
The facility failed to provide effective pain management for four residents by not attempting non-pharmacological interventions before administering opioid medications. Residents with chronic pain and other conditions received medications outside of prescribed orders, and the facility did not document any alternative pain management strategies. The DON confirmed these deficiencies.
Lack of On-Site RD Oversight of Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that a qualified Registered Dietitian (RD) provided the required on-site oversight of the food and nutrition services department after the long-term RD resigned. The RD job description and documented responsibilities showed the position was responsible for resident nutritional care, nutritional assessments, meal service observation, staff education, menu review, audits, and inspection survey participation, while the facility’s documented RD role also included timely weight-loss documentation, review of lab values and meal intake, nutrition-focused physical assessments, and care plan updates related to nutritional needs. During interviews, the dietary manager stated the facility’s long-term RD had resigned and that she was unsure who was covering the position, and she reported that no routine clinical nutrition coverage was being provided on-site. The NHA confirmed the former RD’s last day worked was April 24, 2026, and stated that a remote RD provided coverage after the resignation and also served sister facilities. Time records for the remote RD showed limited off-site hours for the facility over the documented period, and there was no documented evidence that the RD routinely provided on-site oversight of the food and nutrition services department. The corporate RD confirmed the remote RD did not routinely conduct on-site oversight of the dietary department, staff training, direct resident observations for nutritional assessments, or monitoring of meal services. The corporate RD also stated she had no knowledge of untimely nutritional documentation or specific resident nutritional concerns in the facility. The facility therefore did not ensure routinely scheduled on-site consultation and clinical oversight by a qualified RD or other clinically qualified nutrition professional following the resignation of its RD.
Menu Substitutions Not Followed or Reviewed
Penalty
Summary
The facility failed to ensure meals were prepared and served in accordance with the planned menu, failed to provide nutritionally comparable substitutions when menu items were unavailable, failed to document and have substitutions reviewed and signed off by the Registered Dietitian, and failed to notify residents of menu changes. The facility policy stated that substitutions were to be nutritionally adequate, consistent with resident diets and preferences, documented when clinically significant, and reviewed by the RD. However, review of substitution logs for February, March, and April 2026 did not show RD review or sign-off for substitutions made to the planned menu. During observation of the posted Week 2 menu and meal service, the planned Tuesday lunch of sausage and sauerkraut with warm German potato salad, seasoned carrots, and chilled tropical fruit cup was not served as listed. Residents were instead served kielbasa, mashed potatoes, and sauerkraut, and the trays did not contain the planned potato salad, carrots, or fruit cup. On Thursday, the posted lunch menu listed spaghetti and meatballs, Prince [NAME] vegetable blend, garlic bread stick, and assorted cookies, but resident trays did not include garlic bread sticks and green beans were served instead of the planned vegetable blend. Interviews with cognitively intact residents revealed meals were frequently not served as posted, substitutions occurred almost daily, and residents were not informed of last-minute menu changes. One resident reported disliking the meal served and said staff were obtaining food from outside the facility to accommodate her preferences, while other residents stated their preferences were not being honored or updated. A confidential staff interview confirmed that some planned items were not received with the food order, that certain items were unavailable, and that substitutions were not made because there were insufficient replacement items. The corporate RD stated she had no knowledge of items requiring substitution or omission, and the facility did not provide documentation showing the dietary manager’s weekly food orders were submitted for RD review.
Meals Served at Unsafe Temperatures and in Unappetizing Condition
Penalty
Summary
The facility failed to ensure meals were served in a palatable, visually appealing manner and at safe and appetizing temperatures during in-room meal service. A cognitively intact resident reported that lunch items such as kielbasa, mashed potatoes, and sauerkraut included foods she disliked and that her food preferences were not consistently honored or routinely updated. She also stated that meals were frequently visually unappetizing and unpalatable. Observation of her lunch tray showed mostly white-colored food items served on a white plate, the planned chilled tropical fruit cup was missing, and excess liquid from the sauerkraut spread across the plate and mixed with the mashed potatoes and kielbasa, creating an unappetizing appearance. Interviews with six cognitively intact residents revealed that meals were frequently not served according to the posted menus and that residents were not routinely informed of last-minute menu substitutions, which they said occurred almost daily. During lunch tray pass on the second floor, the first meal cart arrived at 12:23 PM and the final tray was delivered at 12:39 PM. A sampled tray for another resident contained mashed sweet potatoes, chopped broccoli, mixed vegetables, and strawberry ice cream. Temperature testing showed the hot items were served at 121 to 127 degrees Fahrenheit, below the safe hot holding temperature of 135 degrees Fahrenheit, and the ice cream was excessively melted and partially liquified. Taste testing found the vegetables were lukewarm, unseasoned, bland, and unpalatable. The Nursing Home Administrator confirmed the observations.
Unsafe Food Storage and Sanitation Practices
Penalty
Summary
Acceptable practices for the storage and service of food were not maintained in the dietary department and in one of two resident nourishment room areas on the second floor. During the initial tour of the dietary department, an employee was observed handling food service equipment without a beard guard to cover facial hair. In the janitor's closet, there was a malodorous mildew smell and an uncovered storage bin full of soiled rags and wet mop heads. The condenser fan inside the produce cooler was corroded with ice crystals, and the dietary manager stated maintenance was aware, but the facility could not provide documented evidence that the ice corrosion had been identified before the surveyor's inspection. In the dry storage room, flour was stored in a bulk container with an ill-fitting lid that exposed the contents, and debris and several deceased insects were observed under the food storage shelving and around the perimeter of the room. In the second floor resident pantry area, the freezer contained an open gallon of chocolate ice cream with ice crystals that appeared to have melted and refrozen and was not properly labeled or dated, along with open cans of energy drinks. The refrigerator contained opened and unlabeled items including sticks of butter that were discolored and deformed, a fast-food sandwich, a Styrofoam container of red-orange liquid, five gallons of whole milk, and another sandwich. The left wall had reddish-brown splatter running down it with a black substance and debris adhered along the perimeter of the room. On revisit, multiple cases of food in the walk-in cooler, walk-in freezer, and dry storage area were left in direct contact with the floor. A dietary staff member reported the food order had arrived the day before but no staff were available to put it away because the dietary manager was busy with other kitchen duties. The NHA confirmed that all food storage areas in the dietary department and resident nourishment room areas were to be maintained in a sanitary manner to ensure food safety.
Unclean and poorly maintained first-floor resident areas
Penalty
Summary
The facility failed to maintain a clean, sanitary, functional, and comfortable environment on the first floor, which remained licensed and available for resident occupancy. Observation of resident rooms 101 through 115 showed numerous unoccupied beds still listed on the state license, and the Nursing Home Administrator confirmed the beds had remained unoccupied for several years but were still available for resident use. The first-floor dining/activity room also had a missing window screen while an on-site optometry clinic was being conducted with five residents seated and awaiting evaluation. Multiple first-floor rooms contained dirty floors, dust, liquid stains, cobwebs, stained or ripped mattresses, missing or broken privacy curtains, and damaged or missing electrical and light switch covers. Several rooms had exposed screws, broken drawers, detached fixtures, hanging call bell equipment, holes in walls, missing screens, and air conditioning units or covers that were damaged, removed, or left exposing the outside environment. Some rooms also contained dirty linens, garbage, bulletin boards stored in resident areas, and furniture or equipment such as dressers, wheelchairs, Geri-chairs, and bedside tables placed in bathrooms or otherwise stored in the rooms. Bathroom observations included toilets with brown, yellow, and black staining; dirty sinks and floors; ceiling tiles with brown discoloration; and visible dead insects in one bathroom. Other bathrooms had detached toilet paper holders, missing toilet seats, exposed bolts, and stained or dirty fixtures. Several rooms also had mattresses labeled broken or bad, stacked mattresses, or air mattresses on the floor. The deficiency was cited under 28 Pa Code 201.18(1)(3) Management.
Care Plans Not Reviewed or Discussed After MDS Assessments
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed, revised, and discussed with residents and/or resident representatives after MDS assessments for Resident 4, Resident 9, and Resident 58. The RAI User’s Manual and facility policies required comprehensive care plans to be developed within seven days of the comprehensive assessment and reviewed and updated after subsequent assessments, with resident participation supported through care plan conferences and advance notice. Facility policy also required interdisciplinary review and revision of care plans following quarterly and comprehensive MDS assessments. Resident 4 was admitted with non-active primary progressive multiple sclerosis and was cognitively intact with a BIMS score of 14. The record showed quarterly and annual MDS assessments were completed, and the resident had active care plans for pain management and fall risk. However, there was no evidence the care plan was reviewed or revised after the February 1, 2026 quarterly MDS or the annual MDS, no evidence of care plan conferences, no evidence the resident or representative participated in care planning, and the care plan target date had expired without update. Resident 9 was admitted with peripheral vascular disease and was cognitively intact with a BIMS score of 15. The record showed quarterly MDS assessments were completed, and the resident had active care plans for pain management and fall risk. There was no evidence the care plan was reviewed or revised after the quarterly MDS assessments, no evidence care plan conferences were held, no evidence the resident or representative participated or were invited to participate, and the target date was no longer current. Resident 58 was admitted with chronic kidney disease and dementia, and a BIMS score of 13 was documented. Quarterly MDS assessments were completed, but there was no evidence the care plan was reviewed or revised after those assessments, no evidence of care plan conferences, no evidence of resident or representative participation or invitation, and the care plan target date had expired. Interviews with the NHA, ADON, and RNAC confirmed care plan conferences were not conducted for these residents and that the care plans were not routinely reviewed or revised following MDS assessments.
Failure to Monitor Weights and Implement Nutritional Interventions
Penalty
Summary
The facility failed to consistently monitor resident weights, ensure accurate and timely weight tracking, and timely implement nutritional interventions for two residents with significant weight loss. The cited policy required resident weights to be obtained in a timely and accurate manner, documented, responded to appropriately, and reviewed by the RD for significant changes and weight loss thresholds. The deficiency involved Resident 30 and Resident 5, both of whom had documented nutritional risk and required ongoing monitoring. Resident 30 was admitted with Alzheimer’s disease, major depressive disorder, and anxiety, and the quarterly MDS showed severe cognitive impairment with a BIMS score of 4 and the need for staff set-up assistance for meals. The care plan identified the resident as at risk for nutritional problems and significant unplanned weight loss. A weight change note documented a 10.9-pound, 7.5 percent loss over 90 days, with suboptimal oral intake and use of nutritional supplements. Weight records then showed 112.7 pounds on March 29, 113 pounds on April 5, and 101.2 pounds on April 12, reflecting an 11.8-pound, 10.4 percent loss in one week. The RD later documented the significant loss and requested a reweigh because of questionable inconsistencies, but the reweigh was not completed and no additional weekly weights were obtained until May 3, 2026. Meal intake documentation for Resident 30 was also incomplete. Out of 90 meal opportunities reviewed for April 2026, staff failed to document intake 34 times, and the documented entries showed multiple meals consumed at 0 to 25 percent. The survey documentation report similarly showed 34 missed meal intake entries out of 90 opportunities. The facility therefore did not consistently document meal intake percentages needed to monitor nutritional status and respond to the resident’s weight loss in a timely manner. Resident 5 was admitted with dysphasia, generalized anxiety disorder, and heart failure, and the admission/5-day MDS showed intact cognition with a BIMS score of 15 and the need for staff set-up assistance for meals. The RD evaluation documented a regular diet with mechanical soft texture and thin liquids, daily Boost Plus, and Liquacel twice daily, with fair appetite, intake generally between 50 and 75 percent, low BMI for advanced age, and risk for protein-calorie malnutrition due to moderate muscle and fat loss. The ordered supplements were not implemented when identified, with Boost Plus started the next day and Liquacel several days later. Weight records showed a decline from 108 pounds to 91 pounds, and a quarterly nutrition note documented a significant 15.7 percent weight loss within 30 days with BMI 16.6 in the underweight range. The recommended Magic Cup three times daily was not initiated until seven days after the significant weight loss was identified, and no additional nutritional monitoring documentation was completed after the RD documented the loss, with no further weights recorded after the resident weighed 90.6 pounds.
Expired Medications and Undated Multi-Dose Vials Found in Medication Rooms
Penalty
Summary
The facility failed to follow its medication storage and disposal policies in two medication rooms by leaving expired medications and improperly dated multi-dose vials available for resident use. Facility policy required medications and biologicals to be stored safely and securely, outdated medications to be removed from stock immediately, and opened multi-dose vials to be dated when first entered and discarded within 28 days unless otherwise indicated. The policy also required nursing staff to inspect medications and expiration dates regularly and remove expired drugs per procedure. In the third floor medication room, expired IV Meropenem preparations and two bottles of Omeprazole Suspension were observed stored in the medication room, and an LPN confirmed they were expired and still available for resident use. In the second floor medication room, an opened vial of Tuberculin PPD Diluted Aplisol and an opened vial of Insulin Lispro had no date showing when they were first opened. The same room also contained five Aptima Unisex Swab collection devices and two Universal Viral Transport collection devices that were expired. The NHA and the Corporate DON reviewed and acknowledged the findings related to the facility's failure to adhere to acceptable medication and biological storage practices, including required labeling, monitoring, and removal of expired medications and supplies from use.
Failure to Consistently Provide Requested Snacks
Penalty
Summary
The facility failed to consistently provide snacks as desired by residents, including bedtime snacks required by facility policy. A review of the Snacks policy showed that HS snacks are to be provided for all residents, and diabetic residents are to receive a nourishing snack consisting of two food groups. During a resident group interview, four residents stated that snacks were not routinely offered in the evenings and that they wanted an evening or bedtime snack. Those residents reported that they had raised the concern at multiple resident council meetings and that it remained ongoing. Two residents stated that dietary staff brought snacks to the unit, but nursing staff did not deliver them to residents, and not all residents knew snacks were available at the nurses station. Review of grievances for the prior six months found no documented grievances about snacks, and the NHA was unable to explain why residents were not consistently offered snacks as desired.
Failure to Protect Resident Privacy During Dental Exams
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents’ medical information and treatment during dental examinations. Review of facility policy and resident rights documentation showed the facility was required to protect identifiable resident information and provide privacy regarding medical treatment and communication. However, during an observation in the first floor dining room, nine residents were seated in the rear of the room while a dentist conducted dental examinations at the front of the room, and the dental assistant was seated at a computer station with the screen visible to others in the room. During the observation, the dentist and dental assistant were heard discussing resident-specific health information in the presence of the residents waiting for examination, and facility staff were observed escorting residents into the room and discussing resident health information with the dentist while other residents were present. There was no curtain, partition, privacy screen, or other barrier separating the resident being examined from the other residents in the room. The dentist confirmed the examinations were conducted in the dining room without a physical barrier or privacy measure, and the Nursing Home Administrator acknowledged that three residents had already undergone dental examinations in this manner before the observation.
Failure to Assess and Monitor Resident After Witnessed Fall
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice when it did not ensure timely assessment, monitoring, evaluation, documentation, and response after a witnessed fall involving a resident who was receiving anticoagulant therapy. The resident had diagnoses including Alzheimer’s disease and lower leg deep vein thrombosis, was severely cognitively impaired, and required staff assistance for transfers and ambulation. Physician orders showed he was receiving Enoxaparin Sodium (Lovenox) 100 mg subcutaneously twice daily, and the medication administration record showed he received the medication as prescribed. Facility investigative documentation and witness statements showed that the resident fell while standing near a window in the second-floor activity room and landed on his bottom after striking a reclining chair. The activity director stated she called nursing staff for assistance, but the facility could not provide documentation identifying which nursing staff responded, nor could it provide nursing assessments, neurological checks, pain assessments, monitoring documentation, post-fall evaluations, or nursing progress notes related to the incident. The investigation was completed three days after the fall by the former DON, and the current DON stated she had no prior knowledge of the event and could not provide additional documentation. Nursing documentation did not show a timely assessment or ongoing observation after the fall. More than two days later, the resident’s wife observed abdominal bruising, swelling, and pain and reported altered mental status, prompting transfer to the hospital. Hospital records showed a large left rectus sheath hematoma with suspected active bleeding and spread into the anterior pelvis, and the resident underwent embolization of the left inferior epigastric artery. The hospital documentation noted that, in the absence of known trauma, the bleeding was believed to be spontaneous and likely associated with anticoagulation therapy.
Failure to Obtain Prescribed Glasses
Penalty
Summary
The facility failed to ensure Resident 28 received necessary assistive devices and assistance to maintain vision abilities. Resident 28 was admitted with bipolar disorder and, during a surveyor interview, stated he had been waiting a long time for his glasses, could not see well without them, and did not have any glasses present in his room. The clinical record included an eye consult dated January 19, 2026, which indicated the resident required glasses and that glasses were to be ordered, but there was no documented evidence in the record that the glasses had been ordered as of May 6, 2026. Outside psychiatric consultation documentation from February 27, 2026, through May 1, 2026, showed the resident repeatedly voiced concern about not having glasses and the effect this had on his mood and well-being. The psychiatric consult dated February 27, 2026, documented that the consultant social worker asked the DON about the resident's glasses and the DON stated she had no knowledge regarding them. During interviews, the NHA stated the glasses were not ordered because the resident reportedly had an unpaid bill for previous glasses, but the NHA could not provide documented evidence that the glasses had been ordered, that an outstanding bill existed, or that the facility assisted the resident in obtaining the prescribed glasses.
Failure to Implement Ordered Restorative Nursing Program
Penalty
Summary
The facility failed to consistently implement a planned restorative nursing program to maintain a resident’s mobility and functional abilities to the extent possible. The resident was admitted with a displaced intertrochanteric fracture of the right femur and, on the Quarterly MDS, required substantial to maximal assistance with lower extremity mobility and ADLs. Physical therapy discharge recommendations called for restorative nursing services consisting of passive ROM and active assistive ROM exercises to both lower extremities for 20 repetitions. The resident’s comprehensive care plan reflected an ADL self-care performance deficit related to decreased mobility and need for staff assistance, but the restorative nursing program was not included in the resident-centered plan of care. Review of the task report and Documentation Survey Report v2 for April and May 2026 showed no documented evidence that staff implemented the ordered restorative nursing program. The clinical record also contained no documented evidence that licensed nursing staff identified, monitored, or addressed the lack of implementation after therapy discharge. The DON acknowledged the facility could not provide evidence that the restorative nursing program had been consistently implemented.
Unsafe Electrical Connections in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free from accident hazards related to unsafe electrical connections and the improper use of extension cords and power strips for resident care equipment and electrical devices in three resident rooms. During an observation in Room 321 Bed 2, the room window was open without a screen and no air conditioning unit was present. A standing fan was positioned in front of the open window, and the fan, resident bed, nebulizer machine, and television were plugged into a multi-outlet power strip that was connected to an extension cord and then into the wall outlet. A tube feeding pump was also plugged into a separate extension cord running underneath the resident's bed and connected into the same power strip arrangement. Additional observations showed a CPAP machine in Room 308 Bed 2 plugged into a power strip extension cord rather than directly into a wall electrical outlet. In Room 306 Bed B, an electric wheelchair charger was observed plugged into an extension cord connected to the wall outlet. During interview, the Nursing Home Administrator confirmed these observations.
Failure to Monitor Enteral Feeding Intake and Weight Loss
Penalty
Summary
Care and services for a resident receiving enteral nutrition were not provided in a way that supported adequate nutritional intake, and the resident experienced significant weight loss while dependent on a PEG tube for 100 percent of nutritional needs. The resident had diagnoses including traumatic brain injury and dysphagia, was severely cognitively impaired, and weighed 99 pounds on the quarterly MDS. Physician orders directed continuous DiabetiSource tube feeding at 68.5 mL/hr with water flushes every 4 hours, but the record did not clarify the start times for the continuous feeding and did not identify a gastric residual amount at which staff were to hold the feeding or notify the physician. Nursing documentation showed varying gastric residual amounts, including 170 cc and 150 cc on separate dates, yet there was no physician order defining when to interrupt the feeding or escalate care. The MARs for March through early May documented tube feeding administration with check marks only, with no amounts infused per shift and no 24-hour totals to show how much nutrition the resident actually received. During observations, the resident was found disconnected from the feeding pump while in the dining/activity room awaiting an ophthalmology appointment and later again while in bed, with the tube feeding off for extended periods before being reconnected. The resident’s weight dropped from 99 pounds to 90 pounds in about three weeks, reflecting a 9-pound loss or 9.09 percent body weight loss. Although nutrition notes documented the resident remained dependent on tube feeding, there was no documented evidence that the RD addressed the significant weight loss until it was triggered on May 6, 2026, and no documented evidence that actual tube feeding intake amounts were reviewed or analyzed to determine whether ordered caloric and nutritional needs were being met. The DON confirmed nursing staff did not calculate or total tube feeding intake amounts, and the facility could not provide documented evidence that the resident’s nutritional status and enteral feeding intake were effectively monitored, evaluated, and managed after the weight loss.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to Resident 28, who was admitted with bipolar disorder. Clinical record review, psychiatric consultation documentation, and staff interviews showed the resident repeatedly expressed concern about waiting for glasses, and outside psychiatric notes dated February 27, 2026, through May 1, 2026, documented that the resident’s depression and emotional well-being were negatively affected by not having glasses. During an interview on May 6, 2026, the resident stated he could not see well without glasses and appeared visibly upset about not having them. The resident also had documented behaviors including anxiety, attempting to self-rise, yelling out, cursing at staff, combative behavior with attempts to hit staff, physical aggression toward peers, removing alarms, and throwing drinks and coffee. The behavior-related care plan, initiated July 4, 2023, had not been revised since June 14, 2024, despite ongoing and escalating behaviors, increased depression, and repeated psychiatric recommendations. Behavioral monitoring documentation showed one intervention was offering snacks, yet during a significant behavioral outburst on May 6, 2026, staff were unable to de-escalate the resident and police were called. A nursing note also documented the resident yelling and stating he needed food, while the DON and NHA were unable to explain why additional snacks or other individualized interventions were not provided or show evidence of effective individualized behavioral health interventions.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents who met criteria for EBP based on wounds. Facility policy stated that EBP includes gowns and gloves during high-contact resident care activities for residents with wounds or indwelling medical devices, and CDC guidance reviewed by surveyors stated that residents with wounds or indwelling medical devices are at increased risk for colonization and transmission of MDROs and should have EBP during high-contact care activities. Surveyors found that Resident 34 had a Stage 3 pressure ulcer on the sacrum, was moderately cognitively impaired, had an EBP order, and had EBP interventions in the care plan, but during observation the room did not contain gowns and gloves for high-contact care activities. An LPN confirmed the supplies were not available in the resident care area. Resident 9 had multiple active wounds, including diabetic wounds on the left plantar and left lateral foot and venous ulcers on the right distal and proximal pretibial areas. Review of the physician orders and care plan did not show that EBP had been implemented despite the presence of these wounds. The ADON and NHA confirmed the facility did not follow its EBP policy for Residents 34 and 9.
Nonfunctioning PTAC Units in Resident Care Areas
Penalty
Summary
The facility failed to maintain a safe, comfortable, and functional environment by not ensuring four Packaged Terminal Air Conditioner (PTAC) units were operational in resident care areas, including one resident room and the Physical Therapy Department. Resident 39 stated during interview that the PTAC unit in her room was not functioning and had been nonfunctional for a long time, at least months, while her roommate preferred air conditioning because she became hot. The report identified three additional nonfunctioning PTAC units in the building, located in the Physical Therapy Department and two other resident rooms. The Director of Maintenance stated that replacement units had been ordered, but he could not provide documentation or evidence confirming that the units or repair parts had actually been ordered. Facility documentation included only pricing estimates dated April 30, 2026, and another estimate dated May 5, 2026; no purchase orders, invoices, shipping confirmations, or other proof of ordering was provided. The Nursing Home Administrator was also unable to provide evidence that timely action had been taken to repair or replace the nonfunctioning PTAC units to ensure residents were provided with a comfortable environment.
Failure to Complete Admission Evaluations and Verify Diet Orders for Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive admission and readmission evaluations and to ensure accurate, verified physician diet orders consistent with a resident’s swallowing needs. A resident with schizophrenia, bipolar disorder, and dysphagia was admitted with an admission evaluation and physician order indicating a mechanical soft diet with nectar thick liquids, despite hospital discharge documentation, nursing assessments, and progress notes lacking evidence to support the need for a mechanically altered diet. The facility did not document any contact with the transferring hospital or the resident’s prior group home to verify the resident’s previous diet consistency, swallowing history, or nutritional needs at the time of admission, contrary to facility policy and the 24-hour admission/readmission chart review checklist. Following a hospital transfer and readmission, the admission evaluation dated March 12, 2026, continued to list a mechanical soft diet with nectar thick liquids, while the physician’s order for that same date specified a mechanical soft diet with thin liquids. This inconsistency between the admission evaluation and the physician’s order was not verified, clarified, or supported by a documented assessment of the resident’s swallowing status. After another hospital transfer and readmission on March 16, 2026, the facility did not complete an admission evaluation as required by policy, and the prior physician order for mechanical soft texture with thin liquids remained active without documented review, clarification, or reassessment to ensure it reflected the resident’s current swallowing needs, prior diet consistency, or clinical condition. A Medical Nutrition and Hydration Evaluation completed by the Registered Dietitian on March 17, 2026, identified the resident’s current diet as mechanical soft with thin liquids but left blank the sections on therapeutic diet prior to admission and prior knowledge of mechanically altered diets, and did not document reconciliation of prior records, clinical history, or swallowing needs. An interdisciplinary care conference on March 18, 2026, attended by nursing, dietary, therapy, administration, and group home staff, documented the resident’s diet as puree with nectar thick liquids, and a subsequent Speech Therapy evaluation on March 20, 2026, recorded group home staff reports that the resident previously tolerated a puree diet with nectar thick liquids and identified oral dysphagia requiring Speech Therapy, with a recommendation for puree with nectar thick liquids. During interviews, the NHA and DON confirmed there was no documented admission evaluation for the March 16, 2026, readmission and no evidence that staff obtained or verified the resident’s diet status from the hospital or group home upon admission or readmissions to ensure accuracy of physician diet orders.
Failure to Ensure Accessible Call Bell and Timely Staff Assistance
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s need to obtain staff assistance by ensuring access to a call bell. The facility’s own policy on call lights, last reviewed January 22, 2026, states that staff must ensure residents have access to the call light and that all staff who see or hear an activated call light are responsible for responding. Resident 1, who was admitted with bilateral lower extremity amputations (left leg above knee and right leg below knee) and was cognitively intact with a BIMS score of 15, required staff assistance for basic needs. During an observation, the resident’s room contained multiple bags of personal items and clothing, and the resident asked the surveyor to hand him the call bell. The call bell cord was found wrapped twice around the undercarriage of the bed frame and positioned behind the resident’s head, out of reach. When the surveyor attempted to provide the call bell, the cord was caught under bags located behind the bed, limiting its length and requiring the resident to bend his arm backward to reach it. The resident could not explain how the call bell came to be placed on the bottom part of the bed behind his head and out of reach. The Nursing Home Administrator acknowledged that the facility had previously discussed clutter in the resident’s room with the resident but that the matter had not been resolved. Resident Council minutes documented concerns from residents, including this resident, about call bell response times and difficulty receiving toileting assistance during the night shift, and a grievance related to call bell response was filed, with audits initiated but no documented resolution at the time of survey. These findings were reviewed with the Nursing Home Administrator and the Director of Nursing, and the deficiency was cited under 28 Pa. Code 201.29(a) Resident rights.
Failure to Secure Windows and Address Suicide Risk Leading to Resident Jumping from Second-Floor Window
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and environmental safety for a resident with significant mental health needs. The resident was admitted with anxiety, major depressive disorder, a documented history of suicide attempts, and prior inpatient psychiatric hospitalizations. The admission MDS showed the resident was cognitively intact, and the PASRR identified a Level II status for serious mental illness. Clinical notes over the ensuing weeks documented persistent and worsening depression, anxiety, pacing, restlessness, and episodes of self-harm behavior such as repeatedly striking his head against the wall. Psychology and psychiatric notes described high anxiety, guarded behavior, feelings of being trapped, visual hallucinations, and major depressive disorder with psychotic disturbance. The resident and spouse, who shared the same room, were known to have had numerous attempted joint suicides with psychiatric hospitalizations. Despite this history and ongoing symptoms, the resident’s care plan for depression and anxiety, initiated shortly after admission, did not include the resident’s documented history of suicide attempts until after the incident. Staff notes repeatedly described escalating anxiety, restlessness, frequent pacing in the room and hallways, and staff difficulty redirecting the resident. Staff and psychiatric providers reported frequent falls likely related to increased restlessness and worsening mood disturbances. The resident expressed a desire to go home, reported feeling dizzy and trapped, and was described as extremely anxious, with his wife identified as a trigger for his distress. Although separation from his wife and psychiatric follow-up were discussed, there is no indication in the report that increased supervision or specific suicide-risk precautions were implemented before the event. On the day of the incident, the RN supervisor assessed the resident for vomiting and difficulty urinating, noted no abdominal distension, and then left the room after the resident became verbally abusive, laid himself on the floor, and then returned to bed independently. Approximately 15 minutes later, the resident’s wife alerted staff that he had jumped out of the second-floor window. The resident had been alone in the room with his wife at the time. Facility investigation and interviews revealed that the window from which the resident exited could be opened fully without restriction, and the screen had been knocked out. The Maintenance Director stated that windows were not routinely inspected and had last been checked a year prior. Observations showed that while some windows in the facility had rubber stoppers limiting opening to a few inches, other windows, including the one in this resident’s room, did not have such devices. The facility’s investigative documentation initially claimed the resident had removed safety screws, but interviews and observations established that no such screws were in place on that window prior to the incident, and that screws were first installed after the event. Additional observations found other windows in resident-accessible areas that could open widely without restriction, demonstrating a broader failure to ensure window security and environmental safety.
Removal Plan
- Resident 1 was transported from the facility to the hospital emergency room and admitted; a safety device was placed in all windows in the facility that would not allow them to open past 4 inches.
- An audit was completed of all windows in residents' rooms and common areas to ensure that window safety devices are in place.
- Residents with a history of suicide attempts will be reviewed to ensure they have psychiatric services in place, psych medications are reviewed, care plans are updated if needed, and a suicide risk assessment is completed; if they trigger for suicide risk, appropriate actions will be taken per the facility Suicide Threats policy.
- Newly admitted residents will have their antidepressant medications reviewed and compared to their hospital discharge instructions to ensure that they are ordered correctly.
- Maintenance will ensure that all windows have been addressed so that they cannot open past 4 inches.
- Maintenance or a designee will perform random window safety audits.
- The DON/designee will audit all new admissions during morning meetings to check for a diagnosis or history of suicide attempts and ensure clinical recommendations are implemented if positive for suicidal ideations.
- The DON/designee will compare hospital discharge summaries for antidepressant medication orders to ensure they match the physician's orders.
- Results of audits will be presented to risk meetings and to the QAPI/QUAPI committee for further review and recommendations.
- All facility staff will be educated on suicide prevention, suicide threats, the six steps to identifying and addressing behavioral symptoms, and window safety.
- Maintenance or the designee will continue to monitor safety window checks.
- The DON/designee will continue to audit all new admissions during morning meetings for suicide-attempt history/diagnosis and implementation of clinical recommendations.
- The DON/designee will continue to compare hospital discharge summaries for antidepressant medication orders to ensure they match the physician's orders.
Failure to Follow Hospital Psychiatric Medication Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to implement procedures to ensure accurate administration of prescribed medications for one sampled resident. Facility policies required a complete admission/readmission chart review within 24 hours to ensure follow-through of physician orders, and specified that psychotropic medications be used only when necessary and managed under the attending physician’s leadership in collaboration with the interdisciplinary team. Despite these policies, the facility did not follow the hospital discharge summary and psychiatric recommendations for the resident’s psychotropic medication regimen. The resident was admitted from an acute care hospital with diagnoses including cerebral palsy, anxiety, and depression, and was documented as cognitively intact with a BIMS score of 15. The hospital discharge summary and psychiatric recommendations indicated that, during a recent inpatient psychiatric stay, the resident’s Fluoxetine dose had been increased from 40 mg to 60 mg daily to address anxiety, panic, and depression, and that Trazodone 25 mg three times daily was to be given as needed for anxiety or sleep. The summary also stated that Lorazepam 0.5 mg twice daily was to be continued, with a recommendation that it be gradually decreased and eventually discontinued due to the resident’s age and documented memory deficits. Upon admission, the facility’s CRNP ordered Fluoxetine 20 mg once daily, later increasing it to 40 mg daily and changing the administration time, but the hospital-recommended 60 mg daily dose was not implemented until nearly two months after admission. Facility records showed that the resident did not receive the recommended 60 mg Fluoxetine dose for several weeks despite the documented need for this dose to manage psychiatric symptoms. Additionally, Lorazepam 0.5 mg twice daily was administered from admission until it was discontinued on a single date without any documented gradual dose reduction as recommended in the hospital discharge summary. During an interview, the DON was unable to provide documented justification for not implementing the recommended medication regimen to meet the resident’s psychiatric needs.
Administrative and Clinical Oversight Failures Leading to Resident Exit Through Second-Floor Window
Penalty
Summary
Facility administration, including the NHA and DON, failed to effectively manage operations to ensure resident safety and maintain residents’ highest practicable physical and mental well-being. The NHA’s job description required directing day-to-day facility functions in accordance with federal, state, and local regulations to ensure quality care, and the DON’s job description required organizing and directing nursing services and resident care. Despite these responsibilities, the facility did not ensure the environment was maintained as free of accident hazards as possible, did not ensure adequate supervision and environmental safety, and did not ensure consistent implementation of facility policies related to resident safety. The facility also failed to ensure that windows were secured to reduce environmental hazards, leaving additional windows unsecured and placing residents at risk for falls and self-harm. The facility further failed to ensure appropriate management and oversight of a resident’s psychiatric care and medication regimen. For one sampled resident with known psychiatric conditions, including suicidal ideation and worsening depression, the facility did not maintain an effective system to identify and mitigate risks. This included failure to ensure appropriate oversight of psychiatric treatment and medication management, such as ensuring that prescribed drugs were given in the correct dose, at the correct time, and monitored for effectiveness and side effects. As a result of these failures, the resident was able to exit the facility through a second-floor window and land on a porch into the snow. These deficiencies were cited as Immediate Jeopardy under F689 (Accidents, 42 CFR §483.25(d)) and related Pennsylvania regulations, based on the lack of effective administrative oversight, monitoring, and enforcement of policies by facility leadership.
Call Bell Not Accessible to Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s need to obtain staff assistance by not ensuring the resident had access to a call bell. Resident 1 was admitted with diagnoses including acquired absence of the left leg above knee and right leg below knee, and the annual MDS dated February 2, 2026, showed the resident was cognitively intact with a BIMS score of 15. During an observation on March 5, 2026, the resident’s room contained multiple bags of personal items and clothing, and the resident asked the surveyor to hand him the call bell because it was not within reach. The call bell cord was observed wrapped around the undercarriage of the bed frame two times and positioned behind the resident’s head, out of reach. When the surveyor unwrapped the cord, it was still limited by bags behind the bed, and the resident had to bend his arm backward to reach it. The resident could not explain how the call bell had been placed out of reach. The NHA stated the facility had previously discussed clutter in the room with the resident but the matter had not been resolved. Resident council minutes also showed concerns about call bell response times, including difficulty receiving assistance for toileting during the overnight shift, and a grievance about call bell response concerns remained unresolved at the time of survey.
Failure to Provide Consistent Access to Fresh Drinking Water
Penalty
Summary
The facility failed to consistently provide fresh drinking water to residents, as required by its own hydration policy, which states that fresh water should be supplied to residents each shift and upon request. During an environmental tour, surveyors observed that the ice chest on the third floor contained stagnant water with visible hair and dead insects, and residents were storing frozen cups of water in the freezer due to the broken ice machine. Staff confirmed that the ice machine had been out of service for two weeks and that residents did not receive fresh water during the shift because of the lack of ice. Additionally, the second-floor pantry's ice chest contained standing water with small flies floating in it. During a group interview, several alert and oriented residents reported that fresh ice water was not consistently provided, despite the facility purchasing bags of ice. Residents stated that staff did not always refill the unit's ice chest, and some residents resorted to making their own ice using plastic cups in the freezer. Residents expressed a preference for ice water, especially in hot weather, and reported that they were sometimes told by staff that no ice was available due to the broken machine. The Nursing Home Administrator confirmed the ice machine was not working and that ice was being purchased, but could not explain why residents' requests for fresh water were not consistently met.
Unsanitary Food Storage and Service Practices Identified
Penalty
Summary
The facility failed to maintain proper food storage and sanitary conditions in both the dietary department and resident pantry areas, as observed during facility tours. In the dishwashing area, there was visible brown and white splatter on ceiling tiles and light fixtures above the dish machine, and a dirty mop was left soaking in a bucket alongside a broom in the janitor's closet. In the kitchen, a bulk container of flour had an unsecured, soiled lid with debris inside. The second-floor resident pantry contained a utility cart with a dirty ice chest and breakfast trays, standing water with flies in the ice chest, and a sticky, black-coated floor. The third-floor pantry had visible dirt, dried food, paper, and plastic debris on the floor, stained baseboards and walls, a missing metal threshold with accumulated dirt, soiled cabinets, a dusty air vent, and a ceiling tile with a red substance. The ice chest in this pantry contained stagnant water with hair and dead insects, and the freezer and refrigerator held unlabeled, undated, and expired food items, as well as containers emitting a strong odor. Employee interviews confirmed a lack of awareness regarding food storage practices, such as residents filling cups with water and storing them in the freezer due to a broken ice machine. The pantries contained multiple food items without proper labeling, dating, or resident identification, including open containers of juice, potato salad, takeout food, cold cuts, cheese, and mayonnaise. The presence of dead insects, offensive odors, and visibly unclean surfaces throughout the dietary and pantry areas demonstrated a failure to follow facility policy and professional standards for food safety and sanitation.
Failure to Resolve and Communicate Grievance Outcomes Related to Call Bell Response
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances and provide timely follow-up with residents regarding the status of their complaints, specifically related to call bell response times. Facility policy requires the grievance official to track all grievances through to their conclusion and to issue written grievance decisions to residents. However, interviews with residents and staff, as well as a review of grievance forms, revealed that multiple residents experienced excessive call bell wait times, sometimes exceeding one hour, and did not receive confirmation or updates regarding the resolution of their grievances. In one instance, a resident reported waiting over an hour for a call bell response, and another grievance indicated residents were left in urine-soaked beds for extended periods due to staff being unaware of their incontinent status. Despite these grievances being filed, there was no evidence that written resolutions were provided to the residents involved. Staff interviews confirmed that there was no consistent process for meeting with residents to review grievance resolutions, and the grievance official did not have a system in place to track filed and resolved grievances as required by policy. Observations further supported these findings, with a call bell going unanswered for 47 minutes and a foul odor of feces present in a resident's room, indicating a lack of timely response. The facility was unable to provide documentation that resolutions to the call bell response time issues were communicated to residents, despite multiple grievances being filed about the ongoing problem.
Failure to Complete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to ensure that discharge summaries, including a recapitulation of the residents' stays, were completed for two discharged residents. For one resident with a history of metabolic encephalopathy and transient cerebral ischemic attacks, clinical records showed that after an episode of altered mental status, the resident was transferred to the emergency room and subsequently admitted to the hospital. The Director of Nursing later informed the Area Agency on Aging that the resident would not be returning to the facility, but there was no documented evidence that a discharge summary or a recapitulation of the resident's stay was completed. Similarly, another resident with diagnoses of spinal stenosis and anxiety disorder requested discharge home with their spouse. The Director of Nursing and physician were notified, and the resident was discharged home after gathering belongings. However, as with the previous case, there was no documented evidence that a discharge summary, including a recapitulation of the resident's stay, was completed. Staff interviews confirmed that no additional documentation was provided to demonstrate that the attending physician had completed the required discharge summaries for either resident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Physician Failed to Document Response to Pharmacist's Medication Recommendation
Penalty
Summary
A deficiency was identified when the attending physician failed to act upon a pharmacist's recommendation regarding a resident's medication regimen. The facility's policy requires that the attending physician document in the medical record whether a pharmacist's recommendation has been reviewed and what action, if any, has been taken. If no change is made to the medication, the physician must provide a rationale for this decision in the resident's record. In this case, the consultant pharmacist recommended a gradual dose reduction for Sertraline 25mg, an antidepressant prescribed to a resident with depressive disorder and weakness. Despite the pharmacist's recommendation, there was no documentation from the attending physician in the resident's clinical record explaining the rationale for continuing Sertraline or for rejecting the dose reduction. The DON confirmed that the physician had been notified of the recommendation via fax but had not responded as of the survey date. This failure to document and address the pharmacist's recommendation was found during a review of clinical records and staff interviews.
Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary antibiotics. A review of the clinical record for a resident admitted with diagnoses including atrial fibrillation and generalized weakness showed that the resident complained of penile discomfort and slightly cloudy urine on one occasion. Two days later, the resident had no urinary complaints and urine was clear and yellow. Despite the absence of consistent clinical signs or symptoms that met McGeer or Loeb criteria for infection, a physician ordered ceftriaxone sodium to treat a urinary tract infection, and the resident received one dose before laboratory results were available. Further review of the laboratory report revealed that the urine culture grew Klebsiella pneumoniae, and the prescribed antibiotic, ceftriaxone, was resistant to this bacterium. The facility’s documentation did not show that the required criteria for initiating antibiotic therapy were met, nor was there justification for the antibiotic order. During an interview, the DON confirmed that no additional documentation or justification could be provided to support the clinical decision to start antibiotic therapy.
Failure to Maintain Safe Operation of Essential Ice Machine Equipment
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the ice machine used for mechanical preparation of ice. Six alert and oriented residents reported during a group interview that fresh ice water was not consistently provided on all shifts because the facility's only ice machine had been broken for approximately two weeks. These residents stated they had to purchase their own bags of ice and have them delivered to the facility. A nurse aide confirmed that the lack of a functioning ice machine resulted in residents not consistently receiving fresh water during their shift. The Nursing Home Administrator acknowledged that the ice machine had been inoperable for about two weeks and that the facility was awaiting an estimate for repairs, during which time staff were purchasing bags of ice to fill unit ice chests and provide ice water passes to residents.
Failure to Maintain Cleanliness Around Enteral Feeding Equipment
Penalty
Summary
Facility staff failed to maintain a clean and sanitary environment for a resident receiving enteral tube feeding. Observations conducted in the resident's room on multiple occasions revealed dried tube feeding residue present on the base of the tube feeding pole, the fall mat on the floor beside the bed, and the surface of the bedside table. These findings were confirmed during an interview with the Nursing Home Administrator, who acknowledged that the tube feeding pole and surrounding areas should be free from liquid tube feed. The resident involved was receiving enteral tube feeding at the time of the observations, and the deficiency was specifically related to the lack of adequate housekeeping services necessary to ensure cleanliness and sanitation of both the resident care equipment and the immediate environment.
Failure to Protect Resident from Neglect During Transfer
Penalty
Summary
A resident with bilateral below-the-knee amputations, generalized weakness, and a need for personal assistance was admitted to the facility and assessed as cognitively intact. The resident's care plan and Kardex specified that all transfers required the assistance of two staff members and the use of a sliding board. Despite this, the resident experienced multiple falls, including an incident where a nurse aide, whose identity was not determined, transferred the resident alone using a sliding board and failed to lock the wheelchair, resulting in the resident falling onto the site of his right leg amputation. There was no evidence that new interventions were implemented after previous falls to prevent recurrence. The facility's internal investigation into the March 15 incident was incomplete, lacking witness statements, staff interviews, and a full written account of the event. The facility was unable to identify or hold accountable the staff member responsible for the unauthorized solo transfer. Additionally, the resident experienced three more falls after this incident, and the facility could not provide further documentation or details related to the March 15 event. These actions and inactions resulted in a failure to protect the resident from neglect as defined by facility policy.
Failure to Investigate and Address Improper Transfer Leading to Resident Fall
Penalty
Summary
The facility failed to promptly and thoroughly investigate an incident of potential neglect involving a resident with bilateral below-the-knee amputations and a documented need for two-person assistance during transfers. Despite care plan instructions specifying the use of a sliding board and two staff members for all transfers, the resident was transferred by a single staff member, and the wheelchair was not locked, resulting in a fall onto the resident's right amputated leg. Previous falls had occurred without new interventions being implemented, and the resident was noted to be cognitively intact at the time of the incident. Following the fall, the facility did not conduct a comprehensive investigation as required by its abuse, neglect, and exploitation policy. There was no documentation of witness statements, staff or resident interviews, or identification of the staff member involved in the transfer. The Director of Nursing confirmed that no investigation consistent with facility policy was completed, and no analysis or corrective actions were documented to address the incident or prevent recurrence. The lack of timely and complete investigation and failure to implement corrective measures constituted a deficiency in responding to alleged violations.
Failure to Provide Timely Nutritional Support and Assessment
Penalty
Summary
A resident with multiple sclerosis and dysphagia was admitted with a care plan identifying them as at risk for nutritional and hydration imbalances due to a history of significant weight loss. Physician orders specified a pureed diet with thickened liquids, fortified foods, and a frozen nutritional treat twice daily, with intake percentages to be recorded. Facility policy required significant weight changes to be reported to the physician and responsible party, and for the interdisciplinary team to assess and document interventions. The resident experienced a significant weight loss over several weeks, as documented in weight records and meal intake logs. Despite the documented weight loss meeting the facility's definition of significant loss, there was no evidence that the physician or responsible party were notified, nor was there documentation of a timely nutritional assessment, new interventions, or care plan revisions in response to the decline. The registered dietitian confirmed that she had not evaluated the resident following the weight loss and that the nutritional regimen was not reviewed or revised until several weeks after the initial decline. There was no documented evidence of timely interdisciplinary reassessment or intervention to address the resident's nutritional status during the period of weight loss.
Failure to Provide Trauma-Informed, Person-Centered Care for Resident with PTSD
Penalty
Summary
The facility failed to develop and implement an individualized, person-centered care plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted with diagnoses including metabolic encephalopathy, major depressive disorder, and PTSD, did not have their PTSD triggers identified in the care plan. Additionally, there were no resident-specific interventions documented to minimize triggers or prevent re-traumatization related to the PTSD diagnosis. A review of the resident's clinical record and staff interviews confirmed that the care plan in effect at the time of review did not address the resident's PTSD needs according to professional standards of practice. The Nursing Home Administrator was unable to demonstrate that culturally competent, trauma-informed care was provided, or that the resident's experiences and preferences were considered to eliminate or mitigate potential triggers for re-traumatization.
Failure to Timely Notify Resident of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide timely notification to a resident regarding the end of Medicare Part A coverage for skilled nursing services. Clinical record review showed that the resident was admitted with diagnoses including weakness and a need for personal assistance. Documentation indicated that Medicare Part A coverage ended on February 18, 2025, but the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) was not issued until the same day coverage ended. An interview with the director of nursing confirmed that the SNF-ABN was not provided prior to the termination of coverage, as required. This deficiency was identified through review of records and staff interviews.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable and maintained at a safe and appetizing temperature for six of ten residents sampled. Observations revealed that a breakfast cart was left unattended on the second floor for an extended period, resulting in food being served at temperatures within the 'Danger Zone,' which is defined as above 41°F and below 135°F. A test tray evaluation showed that the waffles, ham, and hot cereal were served below the required 135°F minimum, making them unpalatable and potentially unsafe. Interviews with six cognitively intact residents confirmed that the food was often served cold and not palatable. Residents reported that delays in tray passing contributed to the issue, with carts frequently left in hallways. The Nursing Home Administrator and the dietary manager acknowledged that the test tray results did not meet regulatory or facility standards, confirming the deficiency in maintaining appropriate food temperatures.
Plan Of Correction
The facility cannot retroactively r the cited deficiency. Meals that are being served are palatable, attractive, and at a safe and appetizing temperature. The Dietary Manager/Designee will re-educate the dietary staff on the facility's Test Tray and Point of Service Food Temperatures policy. The ADON/designee will re-educate nursing staff on timely pass of resident meal trays to help to ensure safe temperature of meals. The Dietary Manager/designee will audit all three meals weekly x 4, then monthly x 3 to ensure acceptable temperatures are served and that they are palatable and attractive on the tray line. Any variations will be corrected immediately and/or offered as training to staff to ensure compliance. The Dietary Manager/designee will audit all three meals weekly x 4, then monthly x 3 on the units to ensure that trays are being served timely and what is being served is palatable, attractive, and that the temperatures are in an acceptable range. Any variations will be corrected immediately and/or offered as training to staff to ensure compliance. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.
Facility Fails to Maintain Safe and Secure Environment
Penalty
Summary
Embassy of Scranton was found to be non-compliant with the requirements for maintaining a safe, clean, and homelike environment as per 42 CFR Part 483 Subpart B and the 28 PA Code. During a state revisit and abbreviated complaint survey, it was observed that the facility failed to maintain the kitchen and laundry room entrance doors in proper working condition. The kitchen's dishwasher entrance doors were broken, unable to be properly closed or locked, and swung off their hinges, posing a challenge for staff transporting tray carts. The Dietary Manager, who was hired in December 2024, confirmed the doors were already in disrepair at that time but could not specify the duration of the issue. Additionally, the laundry room entrance door was also found to be broken, unable to fully close or be secured with a lock. A review of documents revealed that a repair quote for the replacement and installation of both doors was received on August 21, 2024, but there was no evidence that the facility acted on this quote or made any repairs. The Nursing Home Administrator confirmed the broken condition of both doors during an interview, indicating a failure to address the maintenance issues in a timely manner.
Plan Of Correction
The replacement doors for the Kitchen and the Laundry Room entrances have been ordered and will take 6-8 weeks to be manufactured. Once they are received, they will be replaced. The Maintenance Director/designee will conduct an initial audit of existing doors in the facility to ensure that they are in good working order. The Administrator/designee will ensure identified concerns are rectified in a timely manner. The Maintenance Director/designee will educate staff to notify the maintenance department of any safety concerns or repair needs. Any identified needs will be entered into the preventive maintenance program (TELS) by issuing a work order for repair. The Maintenance department will repair the identified concern and/or involve the Administrator to gain approval for purchase of a timely replacement if necessary. The Maintenance Director/designee will audit existing doors in the facility on a weekly basis as part of the preventative maintenance program to ensure that they are in good repair. The Administrator/designee will ensure identified concerns are rectified in a timely manner. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on five out of twenty-one reviewed shifts. Specifically, on March 27, 2025, the day shift had 8.2 nurse aides instead of the required 8.5 for a census of 85 residents. On March 28, 2025, the night shift had 5.5 nurse aides instead of the required 5.6 for a census of 84 residents. On March 30, 2025, the night shift had 4.75 nurse aides instead of the required 5.67 for a census of 85 residents. On March 31, 2025, the day shift had 7.7 nurse aides instead of the required 8.6 for a census of 86 residents, and the evening shift had 7.36 nurse aides instead of the required 7.82 for a census of 86 residents. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios during an interview on April 1, 2025.
Plan Of Correction
The facility will provide a staffing ratio based on July 1, 2024, regulations of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. All facility residents have the potential to be affected by this practice. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. We are also hiring PRN CNAs to assist in covering shifts with call offs or openings in the schedule. We will be using Indeed for advertisements of open positions, participating in career fairs as they are available, and giving sign on bonuses and/or referral bonuses to new hires and our staff. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.
Failure to Meet LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on two occasions, as evidenced by a review of nurse staffing records and staff interviews. On March 26, 2025, the night shift had only 2.0 LPNs instead of the required 2.10 for a census of 84 residents. Similarly, on March 29, 2025, the night shift had 2.0 LPNs instead of the required 2.13 for a census of 85 residents. No additional higher-level staff were available to compensate for this deficiency. The Nursing Home Administrator confirmed the failure to meet the required staffing ratios during an interview on April 1, 2025.
Plan Of Correction
The facility will provide a staffing ratio of one Licensed Practical Nurse per 25 residents on day shift, one Licensed Practical Nurse to 30 residents on evening shift, and one Licensed Practical Nurse per 40 residents on overnight shift. All facility residents have the potential to be affected by this practice. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. We are also hiring additional PRN LPNs to help cover shifts when there are call offs or openings in the schedule. We will be using Indeed for advertisements of open positions, participating in career fairs as they are available, and giving sign on bonuses and/or referral bonuses to new hires and our staff. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure License Practical Nurse ratios are maintained. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.
Non-Compliance with Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two occasions, as evidenced by a review of staffing records and staff interviews. On January 3, 2025, during the evening shift, the facility had 6 nurse aides for a census of 76 residents, falling short of the required 6.91 nurse aides. Similarly, on January 5, 2025, during the day shift, the facility had 7.30 nurse aides for a census of 75 residents, which was below the required 7.50 nurse aides. On both dates, there were no additional higher-level staff available to compensate for the staffing deficiency, resulting in non-compliance with the regulation effective July 1, 2024, which mandates specific nurse aide to resident ratios for different shifts.
Plan Of Correction
The facility will provide staffing ratio based on July 1, 2024, regulation of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. The facility is focusing on retaining current nursing staff. We have only 1 CNA opening at this time, so call offs have been the ongoing issue. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.
LPN Staffing Deficiency on Night Shift
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on one shift out of 21 reviewed. Specifically, on January 4, 2025, during the night shift, the facility had only 1.50 LPNs available, whereas the required staffing level was 1.88 LPNs for a census of 75 residents. This deficiency was confirmed through a review of the facility's weekly staffing records and an interview with the Nursing Home Administrator on January 9, 2025. No additional higher-level staff were available to compensate for this staffing shortfall.
Plan Of Correction
The facility will provide staffing ratio of one Licensed Practical Nurse per 25 residents on day shift, one Licensed Practical Nurse to 30 residents on evening shift, and one Licensed Practical Nurse per 40 residents on overnight shift. All facility residents have the potential to be affected by this practice. The facility is focusing on retaining current nursing staff. We have zero LPN openings at this time, so call offs have been the ongoing issue. The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. NHA or designee will educate staff on incentives and call off policy. Administrator/designee during weekday daily review of nursing schedules will audit to ensure License Practical Nurse ratios are maintained. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.
Deficiencies in Timely Treatment and Medication Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident 6, there was a failure to promptly notify the physician regarding changes in treatment. Resident 6, who was admitted with diagnoses including sepsis and acute kidney failure, experienced a delay in the administration of intravenous fluids. Despite a physician's order for STAT blood work and intravenous fluids, the facility did not notify the physician or CRNP of the delay in initiating the treatment, which was not administered until 18 hours after the order was given. Additionally, the facility did not adhere to the timely administration of medications for Resident 7, who was admitted with chronic kidney disease. Resident 7's medications, including Apixaban, Lidocan patches, Bromfenac Sodium Ophthalmic Solution, and Carbidopa-Levodopa, were administered over 60 minutes past the scheduled time on multiple occasions. This delay in medication administration resulted in doses being given closer together than prescribed, potentially compromising the effectiveness of the medications. Interviews with the CRNP and the Director of Nursing confirmed the facility's failure to notify the physician of changes in Resident 6's condition and the delay in treatment. Similarly, the Director of Nursing acknowledged the late administration of medications for Resident 7, confirming the facility's responsibility to ensure medications are administered in accordance with physician's orders.
Plan Of Correction
The facility is not able to retroactively correct the citations for residents 6 and 7. Medication administration times will be reviewed for current residents and adjusted to ensure medications can be delivered on time. If medications are not delivered on time, the physician or physician extender will be notified. Residents with new IV medications/treatments will be reviewed to ensure that the delivery of the ordered medication/treatment and the insertion of the intravenous line are in place to deliver the IV medication/treatment timely. If this cannot occur, the physician or physician extender will be notified. The ADON/designee will re-educate licensed nursing staff on the facility's Medication Administration policy and the Notification of Changes policy. The DON/designee will audit medication administration times weekly to ensure timely delivery of medication per physician's order, and if not delivered timely that the physician was notified. The DON/designee will also review new orders for IV medications/treatments to ensure they are initiated per the physician order, or if this cannot be delivered timely that the physician or physician extender is notified. These audits will be discussed at the monthly QAPI meeting for further review and recommendations.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on two shifts out of 21 reviewed. On December 8, 2024, during the day shift, the facility provided 8.00 nurse aides instead of the required 8.20 for a census of 82 residents, failing to meet the 1:10 ratio. Additionally, on the same date during the night shift, the facility provided 4.25 nurse aides instead of the required 5.47, failing to meet the 1:15 ratio. No additional higher-level staff were available to compensate for this deficiency. The Director of Nursing confirmed the failure to meet the required ratios during an interview on December 13, 2024.
Plan Of Correction
The facility will provide staffing ratio based on July 1, 2024, regulation of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents during the evening shift, and one nurse aide per 15 residents during the night shift. All facility residents could be affected by this practice. The administrator, the nurse management team, and the nursing scheduler will be re-educated concerning CNA minimal staffing ratios and the appropriate response to unplanned variations in ratios. Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. Results of these audits will be discussed at the monthly QAPI meeting for further review and recommendations.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address and resolve resident complaints and grievances as expressed during Resident Council meetings and verbal grievances. The facility's Grievance Policy, last revised in June 2024, outlines a system to ensure prompt resolution of grievances. However, reviews of the Residents' Council meeting minutes from June, July, and August 2024 revealed ongoing complaints about untimely call bell responses and inconsistent distribution of evening snacks. These issues were repeatedly raised by residents, indicating a lack of effective action by the facility to resolve these concerns. During a group meeting on September 5, 2024, with five residents, it was reported that the facility had not addressed their complaints regarding snack distribution and call bell response times. The facility was unable to provide documented evidence that they had determined whether the residents felt their grievances were resolved. Interviews with the Nursing Home Administrator and Director of Nursing on September 6, 2024, confirmed the absence of documentation showing that resident grievances were addressed in a timely manner and that residents were informed of the facility's efforts to resolve their complaints.
Deficiency in Grievance Policy and Resident Information
Penalty
Summary
The facility failed to develop a comprehensive grievance policy and ensure that necessary information for filing a grievance was available to residents or their representatives. The facility's policy, last revised in June 2024, did not include procedures to support the resident's right to file a grievance anonymously and did not identify the current grievance official. Observations on the nursing units revealed that the posted grievance policy lacked procedural information, such as the location of grievance forms, how to file anonymously, contact information for the grievance official, and the right to obtain a written decision with a reasonable time frame for review. During an interview, the Nursing Home Administrator and Director of Nursing acknowledged the failure to provide residents with the necessary details of the grievance process, including the procedure for filing an anonymous grievance and the locations of boxes for anonymous grievances.
Deficiency in IV Medication Administration via PICC Line
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality as per the Pennsylvania Code Title 49, Professional and Vocational Standards. Specifically, the deficiency involved the improper administration of intravenous medication via a central venous catheter for a resident. The resident, identified as having bilateral lower extremity wounds and sepsis, was admitted with a PICC line. Physician orders required the administration of Cefepime HCL intravenously every 8 hours, but the facility did not have a policy or procedure in place for LPNs to administer or withdraw fluids via a PICC line. The clinical record review revealed that multiple LPNs signed the Medication Administration Record (MAR) as administering the IV antibiotic through the PICC line, despite the facility's Director of Nursing stating that LPNs were not permitted to perform such tasks. An interview with an LPN confirmed that he had not been educated on administering medications through a PICC line and would call an RN to perform the task, yet still signed the MAR as if he had administered the medication himself. This indicates a lack of proper training and supervision for LPNs regarding IV administration and PICC line usage. Furthermore, the Director of Nursing admitted that only a few LPNs had received education on administering medications through PICC lines in the past several years, and there was no evidence of ongoing or yearly education for LPNs on this matter. The facility failed to provide evidence of any current education or supervision regarding IV administration for LPNs, which is a requirement under the Pennsylvania Code. This lack of training and oversight contributed to the deficiency in meeting professional standards of quality in nursing services.
Failure in Pain Management Protocols
Penalty
Summary
The facility failed to provide timely and effective pain management for four residents, as identified in a survey. The facility's policy on pain management requires collaboration with healthcare professionals and the resident to develop and implement interventions to manage pain. However, the facility did not adhere to this policy, as evidenced by the lack of documented attempts at non-pharmacological interventions before administering opioid medications to the residents. Resident 17, who has chronic pain, panic disorder, and major depressive disorder, was administered Tramadol 38 times in both July and August without any documented evidence of non-pharmacological interventions being attempted first. Similarly, Resident 3, with chronic pressure ulcers and peripheral vascular disease, received Hydrocodone-Acetaminophen outside of the prescriber's orders on multiple occasions, with no attempts at non-pharmacological interventions documented. Resident 41, suffering from chronic pressure ulcers and paraplegia, was also given Oxycodone outside of the prescribed parameters, again without documented non-pharmacological interventions. Resident 18, with a history of diabetes, hypertension, and falls with fractures, had their Oxycodone prescription adjusted multiple times in August, yet the medication was administered 35 times without any documented non-pharmacological interventions. The Director of Nursing confirmed the facility's failure to provide non-pharmacological interventions and to follow physician's orders for pain medication administration, leading to the identified deficiencies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 518 citations issued within 25 miles in the last 12 months — including the 6 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Scranton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elan Skilled Nursing And Rehab, A Jewish Senior Li | 0.5 mi | ★★★★★ | 14 | 1 |
| Gino J Merli Veterans Center | 0.5 mi | ★★★★★ | 5 | 0 |
| Dunmore Health Care Center | 1.4 mi | ★★★★★ | 6 | 0 |
| Green Ridge Care Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Marywood Heights | 1.7 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.