Embassy Of Wyoming Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilkes Barre, Pennsylvania.
- Location
- 50 N. Pennsylvania Ave., Wilkes Barre, Pennsylvania 18701
- CMS Provider Number
- 395456
- Inspections on file
- 32
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Embassy Of Wyoming Valley during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a clean, safe, and homelike environment on multiple floors. A resident room and third-floor hallways contained visible dust, dirt, food particles, debris, stains, and liquid splatters, and food debris in the third-floor dining area remained on the floor for an extended period. A hallway handrail near the nurse's station was bent, loosely attached, and had chipped paint with wall damage. Additional issues included beds stored in a second-floor day room and stained, damaged walls in the first-floor library. These conditions were discussed with the Nursing Home Administrator and cited under applicable state management and resident rights regulations.
The facility failed to sustain an effective QAPI program to address previously identified problems with environmental cleanliness and maintenance. Despite policies requiring a comprehensive, data‑driven QAPI process and prior survey findings citing unclean and poorly maintained resident rooms and common areas, a revisit survey found ongoing cleanliness and maintenance issues across multiple floors, including resident rooms, hallways, dining areas, and common spaces. These repeated observations showed that QAPI monitoring did not effectively identify recurring housekeeping and maintenance deficiencies or ensure that corrective efforts were consistently implemented and maintained.
The facility failed to maintain sufficient dietary staffing, which led to meals not being consistently served at palatable temperatures, the planned menu not being followed, and sanitation concerns in the kitchen. Several residents reported that food was frequently cold and not palatable, and a test tray showed hot items below required hot holding temperatures. Review of food temperature logs revealed multiple missing entries, and staffing schedules showed only one cook per shift and three dietary aides on staggered shifts despite a high census. The Food Service Director confirmed that the wrong dessert was prepared instead of the planned menu item and acknowledged being behind on temperature documentation and cleaning tasks after corporate reduced total daily dietary staffing hours, requiring him to assist more with cooking and production.
Surveyors found that the facility failed to maintain sanitary food service conditions and to follow its own food safety policies. In the kitchen, floors had dirt and debris, uncovered sheet cakes were stored in the walk-in refrigerator, vents and ceiling tiles were soiled, and the dishwasher had been inoperable for an extended period while the 3-compartment sink was used for cleaning non-disposable items. Additional observations showed dirty tray line areas, food-stained delivery carts labeled as clean, steam table wells containing food debris, and no documented cleaning schedules for two months. Review of food temperature logs revealed multiple missing entries for breakfast and lunch despite policy requiring temperatures at each meal. For a resident with a personal refrigerator, an undated container of food was found, staff could not determine how long it had been stored, and the posted cooler temperature log had not been updated for several months, indicating that required monitoring and discard practices were not being followed.
Surveyors identified multiple failures to maintain a clean, comfortable, and homelike environment, including resident rooms with dust, food debris, stained toilets, discolored and soiled fall mats, broken toilet paper dispensers, and chipped paint on ceilings. The main dining room was repeatedly found to be significantly colder than the thermostat setting, and several residents reported that it was often cold, with one resident wrapped in a blanket and another asking for the heat to be turned on. Additional observations in a resident pantry and adjacent areas showed stained counters and cabinets, dirt and debris on the floor, a broken electrical outlet, discolored and missing ceiling tiles, a heating/cooling unit filled with food pieces, and handrails with chipped and peeling paint.
The facility failed to maintain safe and palatable food temperatures when the dishwasher became inoperable and remained unrepaired, leading to the use of disposable service ware and Styrofoam containers. Meeting minutes documented that residents repeatedly complained about cold food and requested hot foods be served on plates. Several residents reported that meals were frequently cold or not hot enough. A test tray evaluation on one nursing unit showed multiple hot items, including a hotdog, corn, and pork and beans, were below 135°F and tasted only lukewarm. Review of multiple prior test tray audits by the RD showed ongoing issues with hot foods not being served at palatable temperatures, and leadership confirmed the failure to consistently meet regulatory and facility standards for food temperature.
A resident experienced a fall that led to initiation of neuro checks and eventual transfer to the ED, but the facility failed to maintain accurate and timely clinical documentation. Although 21 neuro assessments were charted as completed, many were not signed until after the ED transfer and the entire set was not locked in the EHR until much later. Nursing progress notes describing the resident’s mental status were entered into the system days after the documented note dates, and CRNP progress notes, including an amended version, were not uploaded into the resident’s electronic record. During this period, facility staff were temporarily covering medical records duties instead of a designated medical records practitioner.
A resident with COPD and dementia sustained an unwitnessed fall with a head strike, resulting in a large head mass while on aspirin and Plavix. An external APN assessed the situation as an acute, critical problem and obtained orders for ED transfer and a CT scan to rule out intracranial hemorrhage. Nursing documentation showed that the resident’s representative was notified of the transfer order and declined it, but did not show that the representative was informed of the head strike, the size of the mass, the critical assessment, the need for CT imaging, or the risks of refusing transfer. In interviews, the representative reported not being told these details, and the NHA could not provide documentation that this information was communicated, resulting in the representative not receiving sufficient information to make an informed decision about the resident’s care.
A resident with cerebral palsy, dysphagia, severe cognitive impairment, and total dependence on staff for eating had a physician order for a coated spoon with all meals. Review of documentation showed the coated spoon was not provided for a substantial number of meals, and direct observation found that a plastic disposable spoon was used despite the tray ticket specifying a coated spoon. A CNA confirmed the coated spoon was frequently omitted and noted the resident sometimes bites down on the spoon, making the coated utensil beneficial. The facility’s administration acknowledged that prescribed adaptive equipment was not consistently provided or used as ordered.
A resident with severe cognitive impairment and a documented history of inappropriate sexual behaviors was able to enter another resident's room and commit sexual abuse due to inadequate supervision and ineffective implementation of care plan interventions. The incident caused significant distress to the affected resident, and staff and family interviews confirmed that the perpetrator's behaviors had been ongoing and not sufficiently managed.
A resident with severe cognitive impairment and mobility deficits was transferred by an agency nurse aide without the required assistance of two staff and without use of a mechanical lift, as specified in the care plan and Kardex. The aide, unfamiliar with the resident's needs and unable to access care plan details, performed the transfer alone, resulting in a spiral fracture of the resident's left tibia. The injury was discovered the next day when the resident complained of leg pain and swelling, and imaging confirmed the fracture.
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. The current FSD lacks the necessary certification, and the RD works remotely part-time, with no documented evidence of face-to-face interactions with residents or frequent consultations with the FSD.
The facility failed to maintain a clean and orderly environment, with issues such as unfinished walls, missing closet doors, and cloudy windows reported by residents. Observations included missing electrical cover plates, ceiling tiles, and baseboard trim, along with debris and ants in the shower room. Residents expressed dissatisfaction with the lack of maintenance and cleanliness.
A facility failed to evaluate the need for physical restraints and obtain informed consent for a resident with anoxic brain damage and osteoporosis. The resident was observed in a wheelchair with restraints they could not remove, without documented medical necessity or consent. Staff interviews confirmed the facility's non-compliance with restraint policies.
A resident with dementia continued to receive Bacitracin ointment for a healed scalp abrasion despite a CRNP's order to discontinue the treatment. The facility staff applied the ointment twice daily for nearly two months after the order to stop, failing to follow professional standards and maintain accurate treatment records.
A facility failed to comply with physician orders for managing a resident's PICC line. The resident, admitted with pneumonia and systemic inflammatory response syndrome, required an emergency PICC kit at bedside, which was not present despite staff documentation. Additionally, there was no evidence of required measurements of the PICC line catheter length being recorded, as confirmed by the Regional Clinical Nurse Consultant.
The facility failed to implement enhanced barrier precautions for a resident with a gastrostomy tube, as required by a physician's order. Observations revealed no signage or PPE instructions outside the resident's room. Additionally, clean towels were improperly stored in a shower room sink, and a resident's Foley catheter urine collection bag was found on the floor, increasing contamination risk. The Infection Preventionist confirmed these lapses in infection control.
A facility failed to provide person-centered care for a resident receiving hemodialysis by not including specific physician orders and care plans for the AV fistula's care and emergency management. The care plan also lacked updates regarding the resident's fluid restriction changes, despite the resident's non-compliance and subsequent discontinuation of the restriction. The DON confirmed these deficiencies.
The facility failed to implement a process for providing pharmacy services and maintaining oversight of the medication dispensing system. Despite policies for emergency medication access, the facility lacked a backup pharmacy and relied on an out-of-state pharmacy with daily courier deliveries. Nursing staff, rather than trained pharmacy personnel, were responsible for restocking the automated dispensing system, and no documentation of pharmacy oversight or staff training was provided.
The facility failed to maintain proper medication storage temperatures on two nursing units. On the Third Floor, medications were stored at 50°F, above the acceptable range, and were moved to another unit. On the Second Floor, a refrigerator lacked a thermometer and temperature log for Ozempic pens. Staff confirmed the need for proper temperature monitoring.
The facility failed to ensure proper oversight and management of its automated medication system as required by Pennsylvania Code Title 49, Chapter 27. A registered nurse was responsible for receiving and filling medications, contrary to the requirement for pharmacist supervision. The Regional Nurse Consultant could not provide evidence of compliance with the code, leading to the deficiency.
A facility failed to notify the State Long-Term Care Ombudsman of a hospital transfer for a resident with atrial fibrillation and COPD. The resident was transferred to the hospital, but there was no documented evidence of a written notice to the Ombudsman. This was confirmed by the NHA.
A facility failed to provide a resident or their representative with written information about the bed-hold policy upon hospital transfer. A review of records and staff interviews revealed no documentation of the policy being provided when the resident was transferred. The Nursing Home Administrator confirmed the lack of documentation.
Embassy of Wyoming Valley failed to comply with menu planning and nutritional adequacy requirements, as evidenced by frequent unapproved meal substitutions and inconsistent meal service. Residents reported receiving incorrect orders and a lack of access to preferred menu options due to supply shortages. The facility's substitution records confirmed numerous instances of unavailable ingredients, and the dietary manager and NHA acknowledged incomplete deliveries from the food service supplier.
The facility failed to serve meals at safe and appetizing temperatures, as confirmed by resident complaints and a test tray evaluation. Residents reported meals, including French fries, were often cold or lukewarm. A test tray showed hot foods were below the required temperature, with chicken and dumplings at 125.5°F and mixed vegetables at 104.8°F. The Dietary Manager and Nursing Home Administrator acknowledged the issue, which compromised dining service quality.
The facility did not meet the required nurse aide to resident ratios for 8 out of 21 shifts, as per Pennsylvania regulations effective July 2024. Staffing records showed deficiencies in nurse aide numbers across several shifts in January 2025, with no additional higher-level staff available to compensate.
The facility failed to meet the required LPN-to-resident ratios on seven shifts, as determined by a review of staffing records and interviews. The facility did not provide the minimum of one LPN per 30 residents on the evening shift and one LPN per 40 residents on the night shift. Specific shifts had fewer LPNs than required for the resident census, as confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day on several occasions. Staffing levels were insufficient, providing only 3.09, 2.81, 2.65, 3.13, and 3.08 hours of direct care per resident on specific days. This was confirmed by the DON.
A resident with severe cognitive impairment sustained fractures due to neglect in a LTC facility. The care plan required two-person assistance for bed mobility, but this was not consistently provided, leading to significant injuries. The facility's investigation highlighted inconsistencies in care provision and documentation.
A resident with moderate cognitive impairment and multiple health conditions lost their lower dentures, as noted in a dental consult. Despite a family grievance and observations confirming the absence of dentures, the facility failed to document efforts to replace them, resulting in a deficiency.
The facility failed to maintain a clean and safe environment, with observations of dirt, debris, and damage in resident units. On the second floor, issues included peeling floor molding, missing vinyl flooring, and brown spots on surfaces. Resident rooms had gouges in walls and brown substances on doors. The spa room had fecal-like substances and mold-like substances on shower curtains. On the third floor, similar issues were noted, including broken fixtures and damaged walls. Interviews confirmed the facility's failure to meet daily maintenance expectations.
The facility failed to maintain sanitary practices for food storage and service, leading to potential contamination and increased risk of food-borne illness. Issues included unlabeled food items, stained ceiling tiles, dead bugs, improperly stored food, and inadequate refrigerator temperatures.
The facility failed to maintain a clean and orderly environment on the second and third floors, with observations of dust, debris, soiled toilets, and damaged fixtures. The DON and NHA confirmed the facility's responsibility to maintain cleanliness daily.
The facility failed to provide timely nursing care and follow physician orders for a resident with a wrist injury and two residents requiring bowel protocols. The facility did not perform a STAT x-ray immediately and failed to administer prescribed constipation treatments, leading to prolonged discomfort and potential complications.
The facility failed to provide meals that accommodated residents' food preferences as outlined in their policy. Interviews with residents revealed that items from the Always Available menu were often not available when requested. A review of food orders showed inconsistency in ordering necessary items, and the dietary manager confirmed the lack of established par levels to maintain supply.
The facility failed to maintain an environment free of potential accident hazards on the second floor resident care unit. An observation revealed an unattended and unlocked crash cart in the Sunshine Terrace area, containing emergency equipment including 24-gauge needles. This was confirmed by a CNA who removed the cart, and later by the NHA and DON who acknowledged the cart should have been locked.
The facility failed to provide necessary behavioral health care to a resident with dementia and schizoaffective disorder. Despite documented negative behaviors and staff reports of increased agitation and combativeness, the facility did not update the resident's behavioral health plan or develop individualized interventions. The resident sustained a fracture due to self-harm, and the facility's immediate intervention was not maintained.
The facility failed to adhere to pharmacy supplies expiration/use by dates on the second floor medication room, with multiple expired items and improperly stored medications observed. An LPN confirmed the findings, and the NHA and DON acknowledged that expired products should have been removed and discarded.
The facility failed to timely obtain radiology/diagnostic services for a resident with dementia and other conditions. A STAT x-ray ordered for the resident's swollen left hand was not conducted on the same day, leading to a two-day delay in diagnosing fractures in the wrist. The delay resulted in delayed treatment and care.
Failure to Maintain Clean, Safe, and Homelike Environment on All Floors
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents on all three floors observed. On the third floor, a resident room was found with visible dust, food particles, debris, and dirt under and around the bed, near the window, and between beds, along with red-colored liquid droplets on the floor. The flooring along the perimeter walls appeared discolored, and baseboards were detached and falling away from the wall, exposing unpainted wall surfaces. Throughout the third-floor hallways, surveyors observed multiple stains on the floors, debris including crushed food particles, straw wrappers, and empty sugar packets, and splatters of a white liquid substance on the hallway floors. In the third-floor dining area, food debris was present on the floor beneath a dining table and remained there when rechecked later the same day. Additional observations on other floors showed further environmental deficiencies. In the third-floor hallway across from the nurse's station, a handrail was bent downward toward the floor, loosely attached to the wall with four screws, with two holes in the wall at the handrail location and chipped and peeling paint on the handrail itself. On the second floor, two beds were being stored in the front day room. On the first floor, the library had brown stains on the wall and a gouged area with missing paint above the baseboard. These conditions were reviewed with the Nursing Home Administrator during an interview, and the deficiencies were cited under 28 Pa. Code 201.18(e)(1) Management and 28 Pa. Code 201.29(a) Resident rights.
Failure to Sustain Effective QAPI Oversight of Environmental Cleanliness and Maintenance
Penalty
Summary
The facility failed to implement and sustain an effective Quality Assurance and Performance Improvement (QAPI) program to identify, monitor, and correct ongoing deficient practice related to environmental cleanliness and maintenance. Facility policy required development and maintenance of a comprehensive, data‑driven QAPI program addressing all systems of care and management practices, including clinical care, quality of life, and resident choices, and using evidence‑based indicators of quality. A prior survey had cited the facility for failing to maintain a safe, clean, comfortable, and homelike environment, specifically noting a failure to provide housekeeping services to maintain a clean and orderly environment throughout the facility. During the revisit survey, observations across multiple floors, including resident rooms, hallways, dining areas, and common spaces, revealed continued concerns with environmental cleanliness and maintenance that were consistent with previously cited issues. These ongoing environmental concerns after the earlier citation showed that the facility’s QAPI program did not effectively monitor the identified housekeeping and maintenance problems, did not adequately analyze underlying causes, and did not ensure that corrective actions were consistently implemented and maintained. The QAPI monitoring activities did not detect the recurrence of deficient practice related to housekeeping and maintenance and did not ensure sustained compliance with regulatory requirements.
Insufficient Dietary Staffing Leading to Cold, Unpalatable Meals and Sanitation Lapses
Penalty
Summary
The facility failed to maintain sufficient dietary staff to safely and effectively carry out food and nutrition services, resulting in meals not being consistently served at palatable temperatures, the planned menu not being followed, and the kitchen not being maintained in a sanitary manner. At the time of survey, the census was 93 residents. Multiple residents reported that meals were frequently cold and not palatable, with several stating they did not like the food and were tired of being served cold meals. One resident stated the facility was aware he did not like the food and that meals were consistently cold, while another generally liked the food but reported it was frequently not hot enough when served. A test tray evaluation on the Third Floor Nursing Unit during a lunch meal showed that a hot dog, corn, and pork and beans were all below the required minimum hot holding temperature of 135°F and were only lukewarm and not palatable. Review of the facility’s Daily Food Temperature Logs for January 19 through January 28, 2026, showed that required meal temperatures were not consistently recorded, with missing breakfast and lunch temperatures on multiple days and missing breakfast temperatures on another day. Dietary staffing schedules for late January showed only one morning cook, one evening cook, and three dietary aides on staggered shifts, with no increase in staffing despite meal service demands and a census of 93 residents. The planned menu for a specific day called for a blonde chocolate chip brownie, but observation of the tray line showed a different dessert—a vanilla cake with wet glazed frosting—was served, and the Food Service Director (FSD) confirmed the planned dessert was not prepared and that he had made the incorrect dessert. The FSD and Nursing Home Administrator reported that corporate reduced total daily dietary staffing hours on December 30, 2025, including cooks, dietary aides, and the FSD, and confirmed that the FSD was required to cook and assist with meal production more frequently, was behind on completion of required food temperature logs and cleaning assignments, and acknowledged sanitation concerns in the kitchen.
Failure to Maintain Sanitary Food Service and Monitor Resident Refrigerator Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain sanitary conditions and safe food handling practices in the food and nutrition services department, as well as failure to monitor food storage in a resident’s personal refrigerator. During an initial tour of the kitchen, surveyors observed dirt and debris on the floor throughout the kitchen, two uncovered sheet cakes on a rolling rack inside the walk-in refrigerator, a dust-covered ceiling vent above the ice machine, and two heavily stained ceiling tiles near the dishwasher. The dishwasher had been inoperable for about one month, and the Food Service Director (FSD) reported that paper products and plastic silverware were being used for meal service while the three-compartment sink was used to clean and sanitize non-disposable equipment. Further observations showed additional unsanitary conditions and lack of cleaning oversight. There was an accumulation of dirt and debris underneath the tray line area, and four food delivery carts identified as clean had visible food stains on interior and exterior surfaces. The steam table wells contained water with food debris from prior meals, and the FSD stated the steam table water was changed weekly. Review of facility records revealed there were no documented cleaning schedules for December or January. Review of Daily Food Temperature Logs showed incomplete documentation, with missing breakfast and lunch temperature recordings on multiple days, despite the facility’s policy requiring food temperatures of hot and cold items to be recorded for all menu items at each meal. The facility also failed to ensure safe and sanitary use of a resident-owned refrigerator. The Resident Refrigerators policy required leftover food to be dated and discarded within three days, and nursing or housekeeping staff were to perform at least weekly checks, including discarding noncompliant food and monitoring refrigerator temperatures. In one resident’s room, surveyors observed a covered plastic container of food in the personal refrigerator without any date, and an LPN could not determine how long the food had been stored or whether it exceeded the three-day discard timeframe. The Cooler Temperature Log posted on the outside of this refrigerator showed the last recorded internal temperature several months earlier, and the administrator was unable to provide additional information demonstrating that staff consistently monitored and documented resident refrigerator temperatures or ensured food was properly labeled and discarded.
Failure to Maintain Clean, Comfortable, and Adequately Heated Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as evidenced by multiple observations of unclean resident rooms, damaged fixtures, and inadequate temperature control. Surveyors observed dust, food pieces, debris, and dirt on the floor and under a window-side bed in one resident room, and in another room found water discoloration stains and pooling near a bed, food pieces and dirt under the bed, and a toilet with brown stains and discoloration on the seat. A toilet paper dispenser in that room had a 2-inch gap between the metal dispenser and the wall, exposing the inside of the wall, with debris from the wall on the floor beneath it. Another resident room contained a blue fall mat with brown and gray liquid and discoloration stains, and a separate room had a broken toilet paper dispenser and a 3-foot line of chipped paint on the ceiling above the window-side bed. The facility also failed to provide comfortable environmental temperatures, particularly in the main dining room, and did not maintain clean and intact common areas. On two separate days, the first-floor main dining room felt cold, with the thermostat set in the mid-70s Fahrenheit while wall thermometers and measured wall temperatures showed actual temperatures in the low-to-mid 60s Fahrenheit. Residents present in the dining room reported that it was often cold, with one resident wrapped in a blanket stating she needed to return to her room after eating because of the cold, another resident asking for the heat to be turned on, and all residents in a group interview expressing concerns about cold temperatures in the dining room. Additional observations in the third-floor Resident Pantry revealed pink liquid discoloration stains on the counter and cabinets, dirt and debris on the floor, a broken electrical outlet, three ceiling blocks with brown water discolorations, a missing ceiling block, and a heating/cooling unit with dozens of food pieces inside the radiator fins. Outside the third-floor Resident Dining room, white handrails were observed with chipped and peeling paint. These conditions were confirmed with facility leadership during interviews.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure foods were served at safe and palatable temperatures for multiple residents when the dishwasher became inoperable and remained unrepaired for an extended period. Facility policy, consistent with 42 CFR 483.60(i)(2), required hot foods to be held at or above 135°F and cold foods at or below 41°F. The dishwasher malfunctioned and became inoperable on November 21, 2025, and the Food Service Director reported it had been broken for approximately one month at the time of survey observation, resulting in the use of disposable paper products and plastic silverware for meal service. Resident Food Committee meeting minutes from late December 2025 and mid-January 2026 documented resident concerns that the dishwasher had not been repaired and that food was being served cold, with specific requests that hot foods be served on plates rather than Styrofoam. Multiple residents reported dissatisfaction with meal temperatures and palatability, stating that meals were frequently cold or not hot enough. During a test tray evaluation on the third floor lunch meal, hot items including a hotdog on a bun, corn, and pork and beans were measured after meal service and found to be below the required 135°F, with temperatures of 111°F, 106°F, and 122.6°F respectively; these items tasted only lukewarm and were not palatable. The Food Service Director acknowledged that these temperatures did not meet facility policy or regulatory requirements. Review of prior test tray audits by the Registered Dietitian on multiple dates from November 2025 through January 2026 showed repeated documentation that hot food items were not being served at palatable temperatures, and the RD confirmed that complaints about cold food had increased since the dishwasher became inoperable. The Nursing Home Administrator confirmed the facility failed to ensure meals were consistently served at temperatures that were palatable and in accordance with regulatory requirements.
Failure to Maintain Accurate and Timely Clinical Documentation After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate, complete, and timely clinical record for one resident following a fall and subsequent transfer to the emergency department. After the resident fell on November 25, 2025, neurological checks were initiated, and 21 assessments were documented as completed. However, the electronic record showed that these neurological assessments were not finalized or locked until January 7, 2026, and 13 of the 21 assessments were not signed as completed until after the resident had already been transferred to the emergency department on November 28, 2025. The lock date, which should represent the point at which documentation is finalized and made read-only, was therefore significantly delayed. Additional documentation issues were identified in the resident’s progress notes and practitioner records. A nursing progress note dated November 27, 2025, and another dated November 28, 2025, both describing the resident as awake, alert, oriented to self, and confused per baseline, were not actually created in the electronic record until November 30, 2025. Furthermore, a CRNP progress note dated November 26, 2025, signed at 5:27 PM, and an amended CRNP note dated November 26, 2025, signed on November 28, 2025, at 6:33 PM, were not uploaded into the resident’s electronic clinical record at all. During an interview, the NHA stated that facility staff were temporarily covering the medical records practitioner’s duties while consultative medical records services were being arranged, during which time these documentation failures occurred.
Failure to Provide Sufficient Information for Informed Refusal After Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident representative was fully informed, in advance and in sufficient detail, of the resident’s condition, the risks and benefits of proposed treatment, and available treatment alternatives so that an informed decision could be made about care. The resident involved had COPD and dementia and had an admission agreement signed by a designated resident representative, who was identified as the responsible party, substitute decision maker, and primary emergency contact. The admission agreement and resident rights documents specified that the resident or representative had the right to be fully informed in understandable language about the resident’s total health status, to participate in treatment decisions, and to be informed in advance by a physician or other practitioner of the risks and benefits of proposed care and treatment alternatives. On the date of the incident, the resident experienced an unwitnessed fall from standing to the floor with a head strike, resulting in a large mass on the head. An external APN evaluated the resident via clinical review and video observation and documented that the resident had a fist-sized mass in the parietal area of the head, was taking aspirin and Plavix, and had diagnoses including dementia. The APN assessed the situation as an acute, critical problem, documented localized swelling, mass, and lump of the head, and determined that the resident required a CT scan to rule out an acute intracranial hemorrhage. The APN obtained physician orders for transfer to the emergency department for further evaluation. A nurse’s progress note documented that the resident fell, struck the back of the head, and that an external APN ordered transfer to the emergency department. The note recorded that the resident representative was informed of the order and declined the transfer. However, the documentation did not show that the resident representative was told that the resident had sustained a head strike, had a large head mass, or that the condition had been assessed as critical. The note also did not document that the representative was informed that the transfer was recommended to allow diagnostic evaluation, including a CT scan, or that the risks associated with refusing transfer after a head injury were explained. In a subsequent interview, the resident representative stated she was told only that the resident had fallen and that an APN had written an order to send the resident to the emergency department, and that facility staff indicated they did not think transfer was necessary; she reported not being informed of the head strike, the size of the mass, the critical assessment, or the concern for intracranial hemorrhage. Staff interviews and record review confirmed there was no documentation that these critical findings, risks, and treatment rationale were communicated, resulting in the resident representative not receiving sufficient, detailed information to make an informed decision about the resident’s care. During an interview, the Nursing Home Administrator was unable to provide any documentation demonstrating that the facility ensured the resident representative received the APN’s findings or a detailed explanation of the risks, benefits, and alternatives related to the recommended emergency department transfer. Specifically, there was no documented evidence that the representative was informed that the resident’s condition was critical, involved a significant head injury, and required emergency evaluation to rule out intracranial hemorrhage. This lack of documented communication and failure to provide detailed information to the resident representative prior to the refusal of transfer constituted the facility’s failure to ensure the representative could make an informed decision regarding the resident’s treatment options, as required by resident rights and facility policy.
Failure to Consistently Provide Prescribed Adaptive Dining Equipment
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide prescribed adaptive dining equipment for a resident with significant cognitive and physical impairments. The resident had diagnoses including cerebral palsy and dysphagia and was documented on a quarterly MDS as being rarely or never understood, having short- and long-term memory problems, being severely cognitively impaired for decision making, and dependent on staff for eating. A physician order dated April 4, 2024, required the use of a coated spoon with all meals. However, review of the resident’s January Task Documentation Report for January 1 through January 28, 2026, showed that the coated spoon was not provided for 31 out of 84 meals served. During a lunch observation on January 29, 2026, the resident’s tray ticket indicated a coated spoon, but a plastic disposable spoon was placed on the tray instead. A nurse aide confirmed at that time that the coated spoon was not provided and further stated that the coated spoon was frequently not included on the resident’s tray. The nurse aide also reported that the resident sometimes bites down on the spoon while being fed and that the coated spoon is beneficial for the resident. The Nursing Home Administrator acknowledged that the facility failed to ensure the prescribed adaptive equipment (coated spoon) was consistently provided and used in accordance with the physician’s orders, in violation of 28 Pa. Code 211.12(d)(3)(5) related to nursing services.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from sexual abuse perpetrated by another resident. One resident with severe cognitive impairment and a history of inappropriate sexual behaviors, including wandering into other residents' rooms and making sexual remarks, was not adequately supervised despite documented ongoing incidents. The care plan for this resident included interventions such as redirection, medication, and seating arrangements to minimize inappropriate behaviors, but these measures did not prevent further incidents. Documentation showed that the resident continued to enter female residents' rooms and make inappropriate comments and contact, even after staff interventions and care plan revisions. On the evening of the incident, the resident entered a room shared by two female residents, both with cognitive impairments, and sat on one resident's bed while she was sleeping. He then touched her breast, causing her significant distress. The roommate, who was cognitively intact, witnessed the event, yelled at the perpetrator to leave, and reported the incident to her daughter. The affected resident was visibly upset, crying, and shaken after the event. Multiple staff and family interviews confirmed the sequence of events, and documentation indicated that the resident responsible for the abuse had a known pattern of similar behaviors that had not been effectively managed. Staff statements and interviews revealed that supervision of the resident with a history of sexual behaviors was inconsistent. Although one-to-one supervision was implemented after the incident, prior to the event, the resident was able to access other residents' rooms without adequate oversight. The facility's failure to provide continuous and effective supervision, despite clear documentation of risk and previous incidents, resulted in a resident being subjected to sexual abuse.
Failure to Follow Care Plan for Safe Transfers Results in Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect by not implementing the individualized care plan intervention requiring the use of a mechanical lift and assistance from two staff members for all transfers. The resident, who had diagnoses including dementia and osteoarthritis and was assessed as severely cognitively impaired, had a care plan and Kardex specifying that all transfers should be performed with a Hoyer lift and two staff. Despite these documented requirements, an agency nurse aide transferred the resident alone and without the mechanical lift. The agency nurse aide was not familiar with the resident's specific care needs and was unaware of the care plan interventions, stating she did not know how to access this information in the facility's system. The aide transferred the resident by herself, placing the resident's arms around her and moving her to bed without assistance or the use of the mechanical lift. This action was not observed by other staff, and no other employees were aware of any falls, improper transfers, or injuries until the following morning when the resident complained of leg pain. Subsequent examination and imaging confirmed that the resident had sustained a nondisplaced spiral fracture of the left tibia. The injury was discovered after the resident was found to have redness, swelling, and pain in her lower left leg. The nurse aide involved had previously signed an attestation acknowledging orientation and training on abuse, neglect prevention, and safe transfer procedures, but failed to follow the resident's care plan, resulting in actual harm.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a full-time qualified director of food and nutrition services in the absence of a full-time qualified dietitian. During an initial tour of the food and nutrition services department, the food and nutrition services director (FSD) revealed that he had been in the position since January 21, 2025, and had a culinary background but lacked the necessary certification to meet federal regulations for a qualified foodservice director. The FSD mentioned that he visits residents for food preferences, but the full-time registered dietitian (RD) had recently quit, and the current RD works remotely, available only via email and telephone. The nursing home administrator (NHA) confirmed that the full-time RD's last day was March 7, 2025, and the current RD works part-time remotely. The NHA acknowledged the facility's failure to provide documented evidence of employing a full-time qualified food service director in the absence of a full-time qualified dietitian. Additionally, there was no documented evidence that the remote RD engaged in face-to-face interactions with residents to ensure appropriate nutritional oversight or that the RD was scheduled for frequent consultations with the FSD.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean and orderly environment in resident areas, as observed on two residential floors and a shower room. Numerous deficiencies were noted, including unfinished spackled walls, missing closet doors, and gouged areas on walls in resident rooms. Residents expressed dissatisfaction with the state of their rooms, noting that promises for repairs had not been fulfilled. Additionally, a missing electrical cover plate was observed in a semi-private room, and a missing ceiling tile was noted in the residents' personal laundry room. Further observations revealed missing baseboard trim and a pile of brown debris resembling dirt in the third-floor shower room, with small ants present. Multiple residents reported cloudy windows that had not been cleaned, affecting their ability to enjoy the view outside. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility's environment should be maintained in a clean and homelike manner, as required by regulations.
Failure to Evaluate and Obtain Consent for Restraint Use
Penalty
Summary
The facility failed to ensure the proper evaluation and use of physical restraints for a resident, as well as to obtain informed consent prior to their use. The facility's policy on a Restraint Free Environment requires that physical restraints should only be used when necessary for medical treatment, and after less restrictive measures have been evaluated and found ineffective. However, the facility did not document any evaluation of the need for restraints or the exploration of less restrictive alternatives for the resident in question. The resident, who was admitted with diagnoses including anoxic brain damage and osteoporosis, was observed in a specialized wheelchair with a chest harness, seatbelt, and pelvic support belt, which they could not remove independently. Despite these restraints being in place, there was no physician documentation justifying their medical necessity, nor was there any evidence of informed consent being obtained from the resident or their representative. The facility's policy requires a physician's order specifying the reason for the restraint, its intended benefit, and the duration of use, none of which were documented. Interviews with facility staff, including a nurse aide and the Director of Rehabilitation, revealed that the facility did not recognize the chest harness and slider belt as physical restraints, and thus did not conduct the necessary evaluations or obtain consent. The Director of Rehabilitation confirmed the lack of compliance with the facility's policies on restraint use, highlighting a significant oversight in the resident's care management.
Failure to Discontinue Treatment as Ordered
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not following a physician's order to discontinue a treatment for a resident. Resident 57, who was admitted with a diagnosis of dementia, had a physician's order dated January 14, 2025, for Bacitracin External Ointment to be applied to an abrasion on the left side of the scalp. On January 20, 2025, a Certified Registered Nurse Practitioner evaluated the wound and issued a new order to discontinue the treatment as the area had healed. However, the facility staff continued to apply the ointment twice daily from January 20, 2025, through March 12, 2025, despite the treatment being discontinued. An observation on March 13, 2025, confirmed that there were no abrasions on the resident's scalp, and the Regional Nurse Consultant acknowledged that the treatment should have been discontinued on January 20, 2025. This oversight indicates a failure in the facility's nursing services to adhere to updated medical orders and maintain accurate treatment records, as required by professional standards and state regulations.
Failure to Comply with PICC Line Management Orders
Penalty
Summary
The facility failed to provide person-centered care by not ensuring compliance with physician orders for the management of a Peripherally Inserted Central Catheter (PICC) line for a resident. The resident, who was admitted with lobar pneumonia and systemic inflammatory response syndrome, had a PICC line inserted for intravenous administration of fluids and antibiotics. Physician orders required the presence of an emergency PICC kit at the resident's bedside or on their wheelchair, to be checked every shift. However, an observation revealed that no emergency PICC supplies were available in the resident's room or on the wheelchair, and a registered nurse confirmed the absence of the kit despite staff documentation indicating otherwise. Additionally, the facility did not adhere to physician orders to measure and record the PICC line catheter length on admission and during weekly dressing changes. A review of the resident's clinical records showed no documented evidence of these measurements being taken as ordered. The Regional Clinical Nurse Consultant confirmed the lack of documentation supporting compliance with these physician orders, indicating a failure to meet the resident's clinical needs.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement enhanced barrier infection control procedures for Resident 38, who was admitted with cerebral palsy and dysphagia, and required enhanced barrier precautions due to a gastrostomy tube. Despite a physician's order dated January 14, 2025, for enhanced barrier precautions, observations on March 12 and 13, 2025, revealed no signage or instructions regarding personal protective equipment (PPE) outside Resident 38's room. Interviews with a Licensed Practical Nurse and a Nurse Aide confirmed the absence of these precautions, contrary to the facility's policy and infection control standards. Additionally, the facility did not properly store clean towels in the Third Floor Nursing Unit's shower room, as observed on March 11, 2025, where towels were placed inside the sink, posing a contamination risk. Furthermore, Resident 36, admitted with neuromuscular dysfunction of the bladder and benign prostatic hyperplasia, had a Foley catheter with the urine collection bag observed lying on the floor on March 11 and 13, 2025. This improper positioning increased the risk of contamination and infection. The Infection Preventionist confirmed the facility's failure to maintain appropriate infection control techniques for Resident 36's Foley catheter.
Deficiency in Hemodialysis Care and Care Plan Updates
Penalty
Summary
The facility failed to provide person-centered care for a resident receiving hemodialysis, as evidenced by the lack of specific physician orders and care plans addressing the care and emergency management of the resident's arteriovenous (AV) fistula. The clinical record for the resident, who was dependent on kidney dialysis due to end-stage kidney disease, did not include detailed instructions for the AV fistula, such as checking for bruit and thrill to ensure its functionality. Additionally, the care plan did not include individualized interventions for monitoring, care, maintenance, or emergency management of the AV fistula site, despite it being the resident's current dialysis access site. Furthermore, the facility did not update the resident's care plan to reflect changes in the resident's fluid restriction orders. Initially, a 1000 cc fluid restriction was ordered due to the resident's diagnosis, but this restriction was discontinued on a later date. However, the care plan was not revised to address the discontinuation of the fluid restriction, even though the resident was noted to be non-compliant with the restriction. The Director of Nursing confirmed the absence of appropriate physician orders and care plans specific to the resident's hemodialysis needs and the failure to update the care plan regarding the fluid restriction.
Failure to Implement Pharmacy Services and Maintain Medication Oversight
Penalty
Summary
The facility failed to implement a process for providing pharmacy services, including access to emergency medications when not available onsite, and did not maintain oversight of the medication dispensing system. The facility's policy indicated that an automated medication system should be used for new admissions, urgent new orders, or immediate medication administration. However, the facility did not provide documentation of pharmacy oversight, including routine monthly audits for expired medications and medication availability. Additionally, the facility lacked a backup emergency pharmacy, despite the policy stating that one should be available. During the survey, it was observed that a courier from the contracted pharmacy delivered medications in bulk, and a registered nurse was responsible for filling the automated dispensing system. The regional nurse consultant confirmed that facility nursing staff, rather than trained pharmacy personnel, were responsible for restocking the system. Although staff had received training from a pharmacist on proper restocking procedures, no documentation of this training or pharmacy oversight was provided. The facility's reliance on an out-of-state pharmacy with daily courier deliveries further contributed to the deficiency.
Medication Storage Temperature Deficiency
Penalty
Summary
The facility failed to ensure that drugs were stored at an acceptable temperature on two nursing units. On the Third Floor Nursing Unit, a medication refrigerator was observed to be storing medications at 50 degrees Fahrenheit, which is above the acceptable range of 36 to 46 degrees Fahrenheit. This was confirmed by a registered nurse who reported the issue to the Director of Nursing, and the medications were temporarily moved to another refrigerator on the Second Floor Nursing Unit. On the Second Floor Nursing Unit, the medication refrigerator was found to contain multiple unopened Ozempic pens without a thermometer inside or a temperature monitoring log available for review. This lack of temperature monitoring was confirmed by Employee 2, who acknowledged that a thermometer should be present and a log maintained. The regional nurse consultant confirmed that all medication refrigerators should have a thermometer and that licensed staff should monitor and record temperatures daily.
Failure to Ensure Proper Oversight of Automated Medication System
Penalty
Summary
The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring proper oversight and management of its automated medication system as required by Pennsylvania Code Title 49, Chapter 27. The code mandates that a pharmacist manager or a contracted pharmacist be responsible for the supervision of the automated medication system, including reviewing and approving policies, ensuring monthly inspections, and maintaining an accountability record for medication stocking and removal. However, the facility did not provide documentation verifying that these oversight activities were conducted, nor did it demonstrate that the contracted pharmacy adhered to the required standards. During the survey, it was revealed that a registered nurse was designated to receive medications from the pharmacy courier and fill the automated medication system, which is contrary to the requirement for pharmacist supervision. The Regional Nurse Consultant was unable to provide documented evidence of the contracted pharmacy's compliance with the Pennsylvania code regarding pharmacy services, including oversight and management of the automated medication system. This lack of documentation and adherence to the required standards led to the deficiency cited in the report.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for one resident. Resident 60, who was initially admitted with diagnoses including atrial fibrillation and Chronic Obstructive Pulmonary Disease (COPD), was transferred to the hospital on June 28, 2024. Upon review, there was no documented evidence that the facility provided the Ombudsman with a written notice of this facility-initiated transfer and the reason for it. This deficiency was confirmed during an interview with the Nursing Home Administrator on March 14, 2025.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide a resident or their representative with written information regarding the facility's bed-hold policy upon the resident's transfer to a hospital. This deficiency was identified during a review of clinical records and staff interviews, which revealed that a resident was transferred to the hospital on January 16, 2025, and returned to the facility on an unspecified date. There was no documented evidence that the facility provided the resident or their representative with written information about the bed-hold policy at the time of transfer. An interview with the Nursing Home Administrator confirmed the absence of such documentation.
Non-Compliance with Menu Planning and Nutritional Adequacy
Penalty
Summary
Embassy of Wyoming Valley was found to be non-compliant with the requirements of 42 CFR Part 483 Subpart B and the 28 PA Code regarding menu planning and nutritional adequacy. The facility failed to follow written planned menus for four of seven residents sampled, as evidenced by frequent menu changes and substitutions without proper notification or consent from the residents. Residents reported that the facility often ran out of food items and blamed supply issues, leading to unapproved meal substitutions and a lack of access to preferred menu options. Interviews with residents revealed dissatisfaction with the meal service, as they frequently received incorrect orders or substitutions without prior notice. Residents expressed concerns about the inconsistency of the "always available" menu, which was often not available, and the lack of weekly menus in their rooms. The Resident Council Meeting Minutes also documented ongoing issues with food supply shortages, including basic items like sugar, butter, milk, and coffee, but there was no evidence that these concerns were addressed by the facility. The facility's substitution records for November 2024 through January 2025 showed numerous instances where planned menu items required substitutions due to unavailable ingredients. The dietary manager confirmed that substitutions were frequently made due to incomplete deliveries from the food service supplier. The Nursing Home Administrator acknowledged the supply shortages and confirmed that the facility was unable to consistently follow the planned menus, resulting in unapproved meal substitutions and inconsistent meal service.
Plan Of Correction
The facility follows the written planned menus. Residents 14, 55, 27, and 56 were not harmed from the deficient practice, nor were the remaining residents. On 1/30/2025, a substitution was made as the food items on the menu did not arrive with the weekly order nor the makeup order the following day. All substitutions are approved by the dietician; all will be audited for appropriateness. The dietary department may "run out of an item," or an item may not have come in. The dietary department is in weekly contact with the vendor regarding missed items and will purchase locally any items that we do not have available for the next meal. Audits will be conducted weekly for 6 weeks of items needed to be purchased locally. Menu changes will be posted next to all menus as soon as a change needed is known. The Food Service Director has in-serviced staff on food substitutions, accurate ordering, and inventory. Surveys will be conducted with residents weekly for 8 weeks to assure they are getting the food items as per menus. Audits will be conducted weekly for 6 weeks by the dietician/FSS on any changes on the menu as well as shopping needs. Eight residents attended the recent food committee on 2/10/2025, with little concerns. Results of audits will be reviewed monthly at the Facility's QAPI meeting for 3 months.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve meals that were palatable and at a safe and appetizing temperature, as evidenced by observations, resident and staff interviews, and test tray results. Four residents reported that their meals were often served cold or lukewarm, with specific complaints about French fries and other hot foods not being served at the appropriate temperature. The Resident Food Committee Meeting minutes from December 2024 and January 2025 also documented resident dissatisfaction with food temperatures, indicating that the issue was ongoing and unaddressed by the facility. A test tray evaluation conducted on January 30, 2025, confirmed that the hot food items, including chicken and dumplings and mixed vegetables, were served below the required temperature, with the chicken and dumplings recorded at 125.5 degrees Fahrenheit and the mixed vegetables at 104.8 degrees Fahrenheit. The Dietary Manager and the Nursing Home Administrator acknowledged the facility's responsibility to ensure meals are served at safe and appetizing temperatures. The failure to maintain proper food temperatures compromised the quality of dining services and posed potential food safety risks.
Plan Of Correction
F804 The facility will provide meals that are palatable and at a safe and appetizing temperature. Residents 1, 5, 6, 14, and 87 had no ill effect from deficient practices. Residents were asked at the Monthly Food Services meeting on 2/10/2025 about palatability and temperature concerns; none voiced any issues. Food items are tasted and temped prior to starting the tray line as well as during the tray line. The trays are then immediately taken upstairs in an enclosed cart. Staff are being notified as soon as the cart arrives for best temperatures and palatability. The Food Service Director has in-serviced staff on food palatability and how to keep temperatures at required levels. A QA project will be completed on temperatures and the time it takes to serve the resident, and what the temperature is at service time. Findings will be reviewed monthly at the building's QAPI meeting. Changes will be made when deemed appropriate. Staff will be in-serviced on palatability.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, §211.12 Nursing Services, effective July 1, 2024. Specifically, the facility did not provide the minimum staffing levels of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight for 8 out of 21 shifts reviewed. This deficiency was identified through a review of the facility's weekly staffing records. On several dates in January 2025, the facility's staffing levels fell short of the required ratios. For instance, on January 24, 2025, the night shift had only 5.17 nurse aides instead of the required 5.93 for a census of 89 residents. Similarly, on January 26, 2025, the day shift had 7.93 nurse aides instead of the required 8.90, and the evening shift had 7.17 nurse aides instead of the required 8.09. No additional higher-level staff were available to compensate for these deficiencies, indicating a consistent failure to meet staffing requirements across multiple shifts.
Plan Of Correction
Facility cannot retroactively correct this deficiency. Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters, and instant interviews from walk-in candidates. Agency staff may be utilized for open shifts if available. The Valentine Open Hiring Event was conducted with interest expressed. Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff. The Director of Nursing/designee will review the ratio daily for compliance. All efforts will be made to meet certified aide staffing ratios. If a call off occurs, all efforts will be made to fill that position. The Director of Nursing/designee will audit the certified aide ratio 1x/week for 4 weeks, then monthly for 2 months. Results of the audits will be presented to the QA committee for review and recommendation.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident ratios on seven out of twenty-one reviewed shifts, as determined by a review of nurse staffing records, resident census, and staff interviews. Specifically, the facility did not provide the minimum of one LPN per 30 residents on the evening shift and one LPN per 40 residents on the night shift. On January 24, 2025, the evening shift had 1.84 LPNs instead of the required 2.97 for a census of 89. On January 26, 2025, the evening shift had 2.22 LPNs instead of 2.97, and the night shift had 1.97 LPNs instead of 2.23 for the same census. On January 27, 2025, the evening shift had 1.91 LPNs instead of 2.90 for a census of 87. On January 28, 2025, the evening shift had 1.69 LPNs instead of 2.87 for a census of 86. On January 29, 2025, the evening shift had 1.84 LPNs instead of 2.87, and the night shift had 2.06 LPNs instead of 2.15 for a census of 86. An interview with the Nursing Home Administrator confirmed these deficiencies.
Plan Of Correction
Facility cannot retroactively correct this deficiency. Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters, and instant interviews from walk-in candidates. Agency staff may be utilized for open shifts if available. The Valentine Open Hiring Event was conducted with interest expressed. Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff. The Director of Nursing/designee will review the ratio daily for compliance. All efforts will be made to meet LPN's ratios. If a call off occurs, all efforts will be made to fill that position. The Director of Nursing/designee will audit the LPN ratio 1x/week for 4 weeks, then monthly for 2 months. Results of the audits will be presented to the QA committee for review and recommendation.
Facility Fails to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct nursing care per resident per day as mandated by the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, effective July 1, 2024. On several dates in January 2025, the facility's staffing levels were insufficient, providing only 3.09, 2.81, 2.65, 3.13, and 3.08 hours of direct care per resident on January 24, 26, 27, 28, and 29, respectively. This deficiency was confirmed during an interview with the Director of Nursing on January 30, 2025.
Plan Of Correction
P5640 The Facility cannot retroactively correct this deficiency. Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters, and instant interviews from walk-in candidates. Agency staff may be utilized for open shifts if available. The Valentine Open Hiring Event was conducted with interest expressed. Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all nursing staff. The Director of Nursing/designee will review the PPD daily for compliance. All efforts will be made to meet the required PPD of 3.2. If a call off occurs, all efforts will be made to achieve the PPD. The Director of Nursing/designee will audit the PPD 1x/week for 4 weeks, then monthly for 2 months. Results of the audit will be presented to the QA committee for review and recommendation.
Neglect Leads to Resident Injury Due to Inadequate Assistance
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 2, was free from neglect, resulting in significant injuries. Resident 2, who had severe cognitive impairment and required assistance with activities of daily living, was not provided with the necessary two-person assistance for bed mobility as outlined in their care plan. This neglect led to the resident sustaining acute displaced comminuted fractures to the left distal femur and right distal tibial. The incident was discovered when Resident 2 was found to be in pain during care activities. Despite the care plan requiring two staff members to assist with bed mobility, there was no documented evidence that this protocol was consistently followed. Employee 2, a Nurse Aide, claimed to have provided care with another staff member, Employee 3, at 8:30 AM, but Employee 3 only confirmed assisting at 2:00 PM. This inconsistency in care provision was a critical factor leading to the resident's injuries. The facility's investigation revealed that Employee 2 did not consistently adhere to the care plan, failing to provide the necessary assistance to prevent harm. This neglect resulted in Resident 2 experiencing pain and discomfort due to the fractures. The lack of proper documentation and adherence to care protocols contributed to the deficiency identified by the surveyors.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely follow-up with required dental services for a resident who was moderately cognitively impaired and had a history of chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney disease, and dysphagia. The resident was admitted with full upper and lower dentures, but a dental consult on April 30, 2024, revealed that the resident had lost the lower dentures and requested replacements. Despite this, there was no documentation in the resident's clinical record indicating that the facility had taken steps to replace the lost dentures. Observations on August 14, 2024, confirmed that the resident was without both upper and lower dentures, and the facility was unable to provide evidence of efforts to address the issue. A grievance from the resident's family dated June 4, 2024, also indicated the dentures were missing, yet no documented follow-up was found. The Nursing Home Administrator could not provide evidence of timely assistance to obtain the necessary dental services, leading to a deficiency under the relevant state codes for nursing and dental services.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for residents, as evidenced by multiple observations of dirt, debris, and damage throughout the resident units. On the second floor, surveyors noted dirt and debris on the floors, peeling floor molding, and missing vinyl flooring in the hallway. In the small dining room, the floor was sticky with dirt, debris, and food particles, and brown spots were observed on a cabinet. Resident rooms exhibited large gouges in walls, food particles on floors, and brown substances on closet doors and bathroom walls. The spa room had a fecal-like substance on the toilet seat, mold-like substance on shower curtains, and a malfunctioning door. On the third floor, similar issues were observed, including gouges in walls, sticky floors, and broken fixtures such as a toilet paper holder. Resident rooms had damaged sheetrock walls, holes, and brown and red spots on walls. The spa room had a ripped shower curtain with mold-like substance and a cracked floor tile. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the expectation for daily maintenance to ensure a clean and sanitary environment, which was not met as per the observations.
Failure to Maintain Sanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the dietary department, several unsanitary practices were observed. Trays of 4-ounce shakes in the tray line reach-in cooler were not labeled with a discard/thaw date, and the dietary manager confirmed that the actual pull date was unknown. In the cooking storage room, a stained ceiling tile was bowed with pots stored directly underneath, and several other stained ceiling tiles and a small missing tile near plumbing were observed. Dead bugs were found inside the light cover of the ceiling light. In the dry storage area, several cases of food were stacked directly on the floor, and two bulk storage bins had ill-fitting lids that failed to secure the contents. The dish machine area had several ceiling tiles with water stains and black-mold-like spots on the surface of the tiles. On the second floor, a gray 8-ounce thermal bowl containing a white powdery substance was found unlabeled and undated in the supply storage area. In the activity/lounge area, the reach-in refrigerator contained two six packs of yogurt with a manufacturer's expiration date that had already passed, and the refrigerator temperature was above the recommended level. Further observation revealed that the refrigerator continued to feel warm, and dried food splatters were observed inside the microwave. The Nursing Home Administrator confirmed that the facility failed to ensure that the dietary department and resident pantry/kitchenette food storage were maintained in a sanitary manner and that foods were properly labeled and dated.
Failure to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to maintain a clean and orderly environment on two resident care units, specifically the second and third floors. Observations on the second floor revealed an accumulation of dust and debris in a discolored ceiling vent in the Spa room, a chipped tile exposing plaster, and a toilet with a brown substance and odor of feces. The shower room bathroom had a large gap between the wall and sink, and the sink appeared to be pulling away from the wall. Mechanical lifts stored in the shower room were heavily soiled, and one had a white cream-like substance on the handle. A soiled fall mat was found inside the Jacuzzi tub, and a chair/bed pressure pad sensor/alarm was lying on the floor, which was soiled with dirt, debris, and small dead bugs. Cobwebs, dead bugs, and debris were observed in the corners and along the sill of the window. The private shower room ceiling vent was heavily coated with lint, and the toilet was soiled with a brown fecal substance. Vents in the ceiling and outside the nurse's station were heavily covered with lint, and ceiling tiles were stained dark brown from what appeared to be water damage. On the third floor, cobwebs, small dead bugs, and debris were observed on the window sill in the large shower room. A soiled adult brief was found in the walk-in tub, and a reclining chair stored in the shower room was soiled with dirt, debris, and a white cream-like substance, with a loose bolt on the seat. The ceiling vent by the window was coated with lint. In the private bath, there was an accumulation of dust and debris in a ceiling vent with scattered brown stains on the ceiling surrounding the vent. An interview with the DON and NHA confirmed that the facility is expected to be maintained daily to provide a clean and sanitary environment for the residents.
Failure to Provide Timely Nursing Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for Resident 52, who was admitted with diagnoses including dementia and reduced mobility. Despite a physician's STAT order for an x-ray of the resident's left wrist and hand due to swelling and pain, the imaging was not performed immediately. The x-ray, conducted two days later, revealed fractures in the wrist. There was also a lack of ongoing nursing assessment and documentation regarding the resident's condition before and after the CRNP's initial assessment, indicating a failure to monitor and address the resident's change in condition promptly and thoroughly. Additionally, the facility did not follow the physician-ordered bowel protocol for two residents. Resident 40, who was cognitively intact and required extensive assistance with ADLs, did not receive the prescribed medications for constipation over several days, despite not having bowel movements. The resident reported ongoing constipation and painful bowel movements, but the facility failed to administer the necessary treatments as per the bowel protocol. Similarly, Resident 15, with diagnoses including congestive heart failure and COPD, did not receive the prescribed bowel protocol treatments timely. The resident went several days without a bowel movement, and the facility failed to administer the necessary medications as ordered. There was also no documented evidence of an assessment for potential complications due to prolonged constipation. These failures were confirmed by the NHA, DON, and Nurse Consultant during interviews.
Failure to Provide Consistent Availability of Menu Items
Penalty
Summary
The facility failed to ensure that residents were provided meals that accommodated their food preferences as outlined in the facility's policy. The policy stated that always available items must be posted and available for residents, including items like grilled cheese, hamburgers, and deli sandwiches. However, interviews with four residents revealed that these items were not consistently available when requested. For example, Resident 32 mentioned that items such as cheese steak hoagies and chicken salad were not available when requested. Similarly, Resident 40 and Resident 59 reported that items from the Always Available menu were often unavailable, including cheese steaks and chicken salad sandwiches. Resident 66 also confirmed that items like cheese steak hoagies were not available, despite being listed on the menu, and provided a tray ticket as evidence. A review of the facility's food orders from April 1 through April 14, 2024, showed that the meat used for steak and cheese was not consistently ordered, which contributed to the unavailability of these items. The dietary manager admitted that no par levels were established to maintain an in-house supply to ensure resident requests could be accommodated. This inconsistency in food availability led to residents being served items they disliked, which is a violation of their dietary preferences and rights as per 28 Pa. Code 211.6 (a) and 28 Pa. Code 201.18 (a).
Unattended and Unlocked Crash Cart in Resident Area
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards on the second floor resident care unit. An observation on April 24, 2024, at approximately 10:42 AM, revealed an unattended and unlocked crash cart in the Sunshine Terrace area, containing emergency equipment including 24-gauge needles. This observation was confirmed by a Certified Nurse Aide (CNA) who subsequently removed the cart from the resident area. During an interview on April 26, 2024, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the cart should have been locked to prevent resident access to potentially hazardous items.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care to Resident 52, who was admitted with diagnoses including dementia, schizoaffective disorder, and bipolar type. The resident's care plan, which was last revised in April 2022, indicated that the resident had negative behaviors such as non-compliance with safety precautions and false accusations towards staff. Despite these documented behaviors, the facility did not update the resident's behavioral health plan or develop individualized interdisciplinary interventions to manage or modify the resident's behaviors effectively. The resident's behavioral symptoms included yelling, cursing, and throwing personal belongings, which were reported by multiple staff members but were not adequately addressed in the care plan. In March 2024, the resident exhibited significant behavioral symptoms, including yelling and making delusional statements. Despite these behaviors, the interventions used by staff were limited to redirection, and the effectiveness of these interventions was not documented. The resident sustained a fracture on March 30, 2024, which was attributed to her hitting a table when angry. The facility's immediate intervention was to pad the table, but this was not observed during a follow-up visit in April 2024. Additionally, the resident's behavior tracking for April 2024 showed no documented behaviors, indicating a lack of ongoing monitoring and assessment. Interviews with staff revealed that the resident had been increasingly agitated, combative, and verbally abusive, yet there was no evidence that the facility had developed and implemented an interdisciplinary approach to manage these behaviors. The facility's failure to provide necessary behavioral health care and services was confirmed during an interview with the Nursing Home Administrator, Director of Nursing, and Nurse Consultant, who were unable to provide evidence of appropriate care and services to meet the resident's behavioral health needs.
Failure to Adhere to Pharmacy Supplies Expiration/Use By Dates
Penalty
Summary
The facility failed to ensure adherence to pharmacy supplies expiration/use by dates on the second floor medication room. Observations revealed multiple expired items, including 62 needleless sterile connectors, a sterile normal saline flush, 10 multifunction red sterile caps, two 27 Gauge needles, two sterile 16 French male catheters, 46 Assure TB Syringe needles, a sterile irrigation tray with piston syringe, and a ureteral self-catheterization kit. Additionally, two RX Destroyer bottles were found leaking a thick sticky black substance with a foul odor, and there were two empty cardboard boxes on the floor. Loose pills were also found in an orange-colored tray and stuck to the floor under a table. An opened sterile dressing change tray was found in a drawer, despite manufacturer instructions indicating it was for single use only. Employee 2, an LPN, confirmed the observed findings. During an interview, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that expired pharmacy products should have been removed and discarded, and the medications should have been wasted. The facility's failure to adhere to these standards resulted in a deficiency as per 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services and 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.
Failure to Timely Obtain STAT X-ray
Penalty
Summary
The facility failed to timely obtain radiology/diagnostic services for Resident 52, who was admitted with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and reduced mobility. On March 28, 2024, a certified registered nurse practitioner (CRNP) assessed the resident for a urinary tract infection and noted swelling and tenderness in the left hand. A STAT x-ray was ordered at 2:42 PM to investigate the swelling and pain. However, the x-ray was not conducted on the same day as ordered. Two days later, on March 30, 2024, imaging results revealed that the resident had anteriorly displaced and angulated fractures of the distal radius and ulna, along with soft tissue swelling. The delay in obtaining the STAT x-ray resulted in a delay in treatment and care for the resident. The Nursing Home Administrator, Director of Nursing, and Nurse Consultant confirmed that the STAT x-rays were not completed as ordered.
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A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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