Embassy Of Wyoming Valley

Based on observation, a review of select facility policy, and resident and staff interviews, it was determined that the facility failed to ensure the required information and resources were made available to residents for filing grievances with the facility and for filing grievances with independent entities, including six out of six residents interviewed during a resident group meeting (Residents 46, 56, 71, 77, 83, and 94).Findings included: A review of the facility policy titled Resident and Family Concerns, last reviewed by the facility on January 21, 2026, revealed it is the policy of the facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal. Notices of resident's rights regarding grievances will be posted in prominent locations throughout the facility. Information on how to file a grievance or complaint will be available to the resident. A review of the facility policy titled Resident and Family Concerns revealed the facility failed to include the following required information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, observations, and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities to meet the interests of and support the physical, mental, and psychosocial well-being of residents, including experiences expressed by 1 out of the 23 sampled residents (Resident 50) and as expressed by residents during a resident group interview (Residents 46, 56, 71, 77, 83, and 94)Findings include: A clinical record review revealed Resident 50 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A care plan initiated May 1, 2024, identified Resident 50 as having a chronic decline in intellectual functioning related to dementia. Interventions included encouraging small group activities. During an interview on January 27, 2026, at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of facility documentation, review of personnel records, and interviews with staff, it was determined the facility failed to ensure the activities program was directed by a qualified professional for one of one activities personnel files reviewed (Employee 1).Findings include: Review of facility documentation revealed the job description for Activity Director stated the primary purpose of the job position is to plan, organize, develop, direct and implement the overall operation of the Activity Department in accordance with current, federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. Continued review of the job description revealed the Activity Director is required to meet one of the following qualifications: be a qualified therapeutic recreation specialist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, review of manufacturer storage guidelines, and review of facility policy, it was determined that the facility failed to ensure drugs and biologicals were properly stored and that expired or improperly labeled medications were removed from use. Specifically, the facility failed to maintain required refrigeration temperatures for injectable medications used to manage blood sugar levels and failed to discard expired or improperly labeled medications, affecting 11 residents medications in two of two medication rooms observed. (Residents 5, 9, 10, 25, 42, 66, 72, 78, 85, 92, and 94).Findings include: A review of manufacturer storage guidelines for injectable blood glucose-lowering medications, including Glargine, Humalog, Trulicity, Lantus, Novolog, and Lispro (injectable medications used to treat diabetes by lowering blood sugar levels), revealed that these medications require refrigerated storage at temperatures between 36 and 46 degrees Fahrenheit to maintain medication stability and effectiveness. Manufacturer guidance further specifies that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, review of select facility policies, test tray evaluation, review of facility-provided documentation, and resident and staff interviews, it was determined the facility failed to ensure foods were served at safe and palatable temperatures for four of 23 residents sampled (Residents 12, 26, 30, and 1).Findings included: According to the federal regulation 483.60(i)-(2) Food safety requirements, the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Review of the facility Safe Food Handling Practices Policy last reviewed January 23, 2026, revealed that hot food must be held at 135 degrees Fahrenheit or higher and cold foods must be held at 41 degrees or lower. During an observation of the dietary department on January 26, 2026, at 10:00 AM, the facility's dishwasher was observed to be inoperable. During an interview at that time, the Food Service Director (FSD) stated the dishwasher…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility-provided documentation, and employee interviews, it was determined the facility failed to ensure the accuracy and completeness of resident medical records for one of 3 closed records (Resident 98). Findings include:Review of the clinical record revealed that Resident 98 was admitted to the facility on [DATE], and subsequently transferred to the emergency department on November 28, 2025. Following a fall on November 25, 2025, neurological check assessments (routine monitoring for signs and symptoms of head or brain injury) were initiated for Resident 98. Review of these neurological assessments revealed a total of 21 assessments were documented as completed. However, the electronic clinical record indicated the neurological assessment documentation was not finalized or locked until January 7, 2026. A lock date represents the point at which documentation is finalized and made read-only to prevent further alteration. Further review revealed that 13 of the 21…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of facility policy, prior survey findings, the facility's Plan of Correction (POC), and observations made during the revisit survey, it was determined the facility failed to implement and sustain an effective Quality Assurance and Performance Improvement (QAPI) program that identified, monitored, and corrected ongoing deficient practice related to environmental cleanliness and maintenance.Findings included:Quality Assurance and Performance Improvement (QAPI), which is a systematic and ongoing process used by a facility to identify problems, implement corrective actions, and ensure those actions are effective and sustained over time, was reviewed. A review of the facility policy titled Quality Assurance Performance Improvement, last reviewed by the facility on January 23, 2026, revealed the facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on outcomes of care and quality of life. The facilities' QAPI program shall address all systems of care and management practices, include clinical care, quality of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility-provided documentation, and interviews with staff and the resident representative, it was determined the facility failed to ensure that the resident representative was fully informed, in advance and in sufficient detail, by the physician or other practitioner, of the resident's condition, the risks and benefits of proposed treatment, and available treatment alternatives, in order to make an informed decision regarding care. This failure occurred for one of three closed records reviewed (Resident 98).Findings include:According to the National Institute of Health (NIH) and National Library of Medicine, Informed Consent is defined as the cornerstone of medicine, ensuring ethical treatment decisions and patient-centered care. Patients have the right to make informed and voluntary treatment decisions. Informed consent is more than merely a signature on a document; it is a communication process between the clinician and the patient. This process ensures that the patient…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of facility policy, clinical records, and staff interviews, it was determined the facility failed to ensure physician orders accurately reflected a the resident's documented resuscitation status for one of 23 residents reviewed (Resident 73).Findings include:A review of a facility policy titled Residents' Rights Regarding Treatment and Advanced Directives, last reviewed by the facility on [DATE], revealed it is the facility policy to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive. An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated. Review of the clinical record revealed that Resident 73 was admitted to the facility on [DATE], with diagnoses to include malignant neoplasm of the right breast (breast cancer) and vascular dementia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records and a staff interview, it was determined the facility failed to timely complete a significant change Minimum Data Set assessment for one of 23 residents reviewed (Resident 8). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2025, indicated that a significant change MDS assessment is required to be performed when a terminally ill resident enrolls in a hospice program. The assessment reference date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same as or later than the date of the hospice election statement, but not earlier than). A significant change MDS assessment must be performed regardless of whether an assessment was recently conducted on the resident. A clinical record review revealed that Resident 8 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, select policy review, and staff interview, it was determined the facility failed to maintain an environment free from accident hazards for one of 23 sampled residents (Resident 5).Findings include: A review of the facility's Medication Administration policy, reviewed January 23, 2026, revealed that when administering medications to a resident, staff are to observe consumption of the medication. Clinical record review revealed that Resident 5 was admitted to the facility on [DATE], with a current diagnosis of diabetes (a chronic condition causing high blood sugar because the body cannot produce enough hormone to lower the levels to a normal range), chronic pain, and iron deficiency (low iron levels in the blood). A quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) completed on October 28, 2025, revealed the resident had a BIMS of 3 (Brief Interview for Mental Status, a tool to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, facility policies, and staff interviews, it was determined the facility failed to develop and implement individualized, person-centered interventions to manage dementia-related behavioral symptoms in order to promote resident safety and to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident out of 23 residents sampled (Resident 7).Findings include: A review of the facility policy titled Dementia Care last reviewed by the facility on January 21, 2026, indicated the facility will provide appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach. The care plan interventions will be related to each resident's individual symptomology and rate of dementia progression with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and staff interview, it was determined the facility failed to ensure the provision of adaptive dining equipment as prescribed to support safe eating for one of 23 sampled residents. (Resident 16)Findings include: A review of the clinical record revealed that Resident 16 was admitted to the facility on [DATE], with diagnoses to include cerebral palsy (group of permanent movement, muscle tone, or posture disorders caused by abnormal brain development or damage before, during, or shortly after birth) and dysphagia (difficulty swallowing). Review of a quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 2, 2025, indicated that a BIMS interview (Brief Interview for Mental Status, a tool to assess cognition) should not be completed with the resident due to the resident being rarely or never understood, had short term and long term memory problem, was severely…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of the facility admission agreement and arbitration documents, and staff interviews, it was determined the facility failed to ensure arbitration agreements were implemented to ensure that an arbitration agreement allowed for the mutual selection of a neutral arbitrator for one resident out of three discharged residents reviewed. (Resident 98). Findings include: A clinical record review revealed Resident 98 was admitted to the facility on [DATE]. A review of an admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 13, 2025, revealed that Resident 98 is severely cognitively impaired with a BIMS score of 02 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 00 to 07 indicates cognition is severely impaired).A clinical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's abuse policy, clinical records, investigation reports, and interviews with residents and staff, it was determined that the facility failed to assure that one resident (Resident 1) out of six sampled residents was free from sexual abuse perpetrated by another resident (Resident 2).Findings included:A review of the current facility policy titled Abuse, Neglect and Exploitation, last reviewed by the facility on February 19, 2025, revealed it is the policy of the facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. A review of Resident 2's clinical record revealed admission to the facility May 20, 2025, with diagnoses to include dementia (a condition characterized by progressive or persistent loss of intellectual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interview and a review of employee qualifications it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian. Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. During initial tour of the food and nutrition services department on March 11, 2025, at 6:20 PM the food and nutrition services director (FSD) stated that he had been the FSD since January 21, 2025. The FSD stated that he had a culinary background but did not yet have a certification to meet the requirements for a qualified foodservice director based on current federal regulation. The FSD stated that he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and resident and staff interviews, it was determined the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment in resident areas on two of two resident floors (second floor and third floor residential units, and third floor shower room). Findings included: An observation on March 11, 2025, at 8:38 PM in resident room [ROOM NUMBER] revealed numerous spackled areas on the wall throughout the room. The closet door was missing. Interview with Resident 39, at the time of the observation, revealed he was admitted to the facility on [DATE]. He reported the walls have been unfinished since his admission to the facility. He continued, they've been promising me a closet door since I got here, but as you see, that hasn't happened. An observation on March 11, 2025, at 8:50 PM in resident room [ROOM NUMBER] revealed a large, gouged area of the wall outside the bathroom and an unknown red substance splattered on the ceiling above the resident's bed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of clinical records and select facility policy, and staff interview, it was determined the facility failed to ensure the evaluation of a resident's need and use of physical restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom, and failed to obtain informed consent prior to the use of the physical restraint for one of one sampled resident with restraints (Resident 1). Findings included: A review of the facility's policy titled Restraint Free Environment last reviewed by the facility February 19, 2025, revealed that physical restraint refers to any method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to: Applying leg or arm restraints, hand mitts, soft ties, or vests that the resident cannot remove. Using devices…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, a review of clinical records, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to follow a physician order to discontinue a treatment for one of 21 sampled residents (Resident 57). Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, and staff interviews, it was determined that 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, failed to maintain the availability of prescribed emergency supplies, and failed to meet the resident's clinical needs for one of 21 sampled residents (Resident 31). Findings include: A review of clinical records revealed Resident was admitted to the facility on [DATE], with diagnoses to include lobar pneumonia (type of lung infections that affects an entire lobe of the lung), and systemic inflammatory response syndrome of non-infectious origin (widespread inflammatory response to a non-infectious trigger). A review of Resident 31's hospital records, including the PICC Insertion Documentation dated January 30, 2025, indicated the resident underwent placement of a single-lumen PICC line (a peripherally inserted central catheter, also called a PICC…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of clinical records, select facility policy, observations, and staff interviews, it was determined the facility failed to implement enhanced barrier infection control procedures for one out of 21 residents sampled (Resident 38), properly store clean towels designated for resident use in one out of two shower rooms on the Third Floor Nursing Unit, and maintain infection control practices related to reduce the potential for infections for one (Resident 36) out of two sampled residents with an indwelling urinary Foley catheter (flexible tube which is placed in the bladder to drain urine). Findings include: A review of facility policy titled Enhanced Barrier Precautions, last reviewed by the facility on February 19, 2025, revealed it is the facility policy to expand the use of personal protective equipment and refer to the use of gowns and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug-resistant organisms (MDROs) to staff hands and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined the facility failed to provide person-centered care for one resident out of one resident receiving hemodialysis. (Resident 87). Findings include: A review of the clinical record revealed that Resident 87 was admitted to the facility on [DATE], with diagnoses to include end-stage kidney disease with dependence on kidney dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). According to the clinical record, the resident had a left upper arm arteriovenous fistula (an AV fistula is a connection that's made between an artery and a vein for dialysis access. A surgical procedure, done in the operating room, is required to stitch together two vessels to create an AV fistula). Current physician orders dated January 30, 2025, indicated dialysis days and times (Monday, Wednesday, Friday at 11:30 AM), specific instructions for the left arm fistula, limb alert left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of select facility policy, and staff interviews, it was determined that the facility failed to implement a process for providing pharmacy services, including access to emergency medications when not available onsite, and failed to maintain oversight of the facility's medication dispensing system. Findings include: A review of the facility Medication Ordering and Receipt Emergency Boxes and On-Site Stores Policy reviewed February 19, 2025, indicated the contract pharmacy supplies an On-site Stores (Pyxis like system, an automated, medication system, located in the facility) to be utilized by the facility in the case of new admissions, urgent new orders, received after-hours, or when immediate medication administration is required. Procedures to include, On-site Stores medication is secured in compliance with Federal, State, and Local regulations for drug storage and inaccessible to unauthorized persons. If the On-site Stores is not exchanged regularly, a pharmacy representative will perform an on-site audit inspection and remove expired drugs on a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of select facility policy, observation, and staff interview it was determined the facility failed to ensure that drugs were stored at an acceptable temperature on two of two nursing units. Findings include: Review of the facility Medication Storage policy last reviewed February 19, 2025, indicated that medications and biologicals (medications that come from living organisms) are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a secured refrigerator with a thermometer to allow temperature monitoring. An observation of the medication refrigerator located in the nurse's station on the Third Floor Nursing Unit on March 11, 2025, at 7:20 PM in the presence of employee 3 (registered nurse) revealed that various medications which required refrigerator were being stored in the refrigerator. The thermometer in the refrigerator read 50 degrees Fahrenheit. A second observation of the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of the facility's automated emergency medication system, applicable state regulations, facility policies, and staff interviews, it was determined that the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring pharmacy services necessary for daily pharmacy operations according to state requirements of Pa. Code title 49. Findings include: A review of Pennsylvania Code title 49, part I, subpart A, chapter 27 - STATE BOARD OF PHARMACY, 49 Pa. Code § 27.204 - Automated medication systems revealed the following: (a) This section establishes standards applicable to licensed pharmacies that utilize automated medication systems which may be used to store, package, dispense or distribute prescriptions. (b) A pharmacy may use an automated medication system to fill prescriptions or medication orders provided that: (1) The pharmacist manager, or the pharmacist under contract with a long-term care facility responsible for the dispensing of medications if an automated medication system is utilized at a location which does not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, a review of the facility's planned cycle menus, and resident and staff interview it was determined that the facility failed follow written planned menus for four of seven residents sampled. (Resident 14, 55, 87, and 56). Findings included: Review of the facility policy titled Menu Substitutions last reviewed by the facility January 2024, revealed that menu substitutions/changes shall be made to the planned menu in an emergency situation only and not for the convenience of the facility. At the time of the survey ending on January 30, 2025, the facility census was 86 residents. On January 30, 2025, at 9:50 AM resident 14 reported the menu changes occurred frequently, and staff only notified him when they are picking up his breakfast tray. He stated that they run out of food and blame the truck for not supplying food to the facility. Interview with Resident 14 on January 30, 2025, at 10:00 AM revealed that the always available menu is not consistently available- it's now changed to IF…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of food committee minutes, resident and staff interviews, and test tray results, it was determined the facility failed to serve meals that were palatable and at a safe and appetizing temperature for four of the 7 residents sampled (Residents 1, 56, 14, and 87) Findings include: According to the federal regulatory guidance at 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. Review of the Resident Food Committee Meeting minutes dated December 11, 2024, revealed the residents were asked if the temperature of the hot/cold foods were appropriate. The response indicated was no, with the added comment: cold meals at dinner. Review of the Resident Food Committee Meeting minutes dated January 15, 2025, revealed the residents were asked if the temperature of the hot/cold foods were appropriate. The response indicated was no with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records and staff interview, it was determined that the facility failed to timely follow-up with required dental services for one Medicaid payor source resident out of two residents sampled (Resident 49). Findings include: A clinical record review revealed Resident 49 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD), atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal), chronic kidney disease, and dysphagia (difficulty swallowing). Review of an Annual Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated April 15, 2024, revealed that Resident 49 was moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment. Findings include: Observations on June 27, 2024, at approximately 8:55 AM of the second floor resident unit revealed the following: Dirt and debris was observed on the floors throughout the hallway. Floor molding was observed peeling off the wall in the hallway. A piece of the vinyl flooring was missing in the hall. Observation in the small resident dining room revealed dirt, debris and food particles on the floor. The floor was sticky next to the supply cabinet. Multiple dried brown spots were observed on the cabinet next to the refrigerator. Observation in resident room [ROOM NUMBER] revealed large gouges in the wall. Food particles were observed on the floor. Spots of brown substance were observed on the closet doors. Observation in the bathroom of this resident room, revealed brown spots…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness, in the dietary department and the second- floor resident food storage area. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). The initial tour of the dietary department was conducted with the facility's food services manager on April 23, 2024, at 9:27 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment on two of two resident care units. (Second and Third Floor) Findings include: Observations on April 24, 2024, at approximately 10:37 AM of the Unit 2 second floor revealed the following: An accummulation of dust and debris in a discolored ceiling vent in the Spa room. The tile directly under the sink on the left-hand side of the wall was chipped exposing plaster on the wall. The toilet to the left upon entrance to the room, was observed as you walk into this room was noted to have a brown substance with an odor of feces covering the seat and in the bowl. In the shower room bathroom, there was a large gap observed between the wall and sink, which extended the length of the sink. The sink appeared to be pulling away from the wall. The bases of the mechanical lifts that were stored in the shower room were heavily soiled with dirt and debris. One of the lifts had a white cream like substance on the handle. A soiled fall mat was observed inside the Jacuzzi tub…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policy and clinical records, and interviews with staff, it was determined the facility failed to provide nursing services consistent with professional standards of practice to ensure that licensed nurses properly evaluated and provided nursing care for a change in condition for one resident out of 20 sampled (Resident 52) and failed to follow physician orders for bowel protocol for two residents out of 20 sampled (Resident 40 and 15). Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility planned menus and select facility policy, observations, and resident and staff interviews, it was determined that the facility failed to ensure residents were provided meals that accommodated food preferences for four of 20 residents reviewed (Residents 59, 66, 32, and 40). Findings Include: A review of a facility policy entitled Alternative Menu Program that was last reviewed by the facility on January 18, 2024, indicated that always available items must be posted by the menu on all floors for the residents to see and all items must be available for the meal. There are three menu items on the alternate menu that includes grilled cheese, hamburger on a bun, and a deli sandwich. Based on resident decisions from the facility's monthly Food Committee meeting, two selections per the resident's selection will be added to the permanent always available menu items. The two selections will be rotated monthly. A review of the facility's April 2024 events/activities handout that was provided to each resident listed that the monthly Always Available Menu for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards on one of two resident care units. (Second Floor) Findings include: An observation conducted on April 24, 2024, at approximately 10:42 AM, revealed a crash cart was in the resident area, the Sunshine Terrace on the second floor. The cart was unattended and not locked, and contained emergency equipment that included 24-gauge needles. Employee 1, Certified Nurse Aide (CNA) confirmed the above observation at this time and removed the cart from the resident area. During an interview on April 26, 2024, at 1:46 PM with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the cart should have been locked to prevent resident access to potentially hazardous items. 28 Pa Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 201.18 (e) (2.1) Management

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of select facility policies/reports and clinical records, and staff, and resident interviews it was determined that the facility failed to provide necessary behavioral health care to promote the highest practicable physical and psychosocial well-being of one resident out of 20 sampled (Resident 52). Findings include: A review of facility policy entitled Behavioral Assessment, Intervention and Monitoring last reviewed January 18, 2024, indicated that behavioral symptoms will be identified using facility-approved behavioral screening tolls and the comprehensive assessment. The nursing staff will identify, document and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition including the onset, duration, intensity, and frequency of behavioral symptoms, any precipitating factors or relevant factors, appearance and alertness of the resident and related observations. New onset of changes in behavior will be documented regardless of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of manufacturer's directions for use, observation, and staff interview, it was determined that the facility failed to ensure adherence to pharmacy supplies expiration/use by dates on one of three resident units (Second Floor). Findings include: Observations on [DATE], at 9:00 AM of the facility's second floor medication room revealed the following: There were 62 needleless sterile (germ free) connectors that expired on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. One sterile normal saline flush found on the floor under a table with an expiration date of [DATE]. 10 multifunction red sterile caps that expired on [DATE]. Two 27 Gauge x ½ inch precision BD glide needle that expired on [DATE]. Two sterile 16 French [NAME] Male Catheter that expired on [DATE]. 46 Assure TB Syringe 28 Gauge x ½ inch needles that expired on [DATE]. One sterile irrigation tray with piston syringe that expired on [DATE]. A ureteral self-catheterization kit that expired on [DATE]. Two RX…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility failed to timely obtain radiology/diagnostic services to meet the needs of one resident of 20 sampled (Resident 52). Findings include: Review of clinical record revealed that Resident 52 was admitted to the facility on [DATE], with diagnoses to include dementia (a major neurocognitive disorder that affects memory, thinking and interferes with daily life) without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and reduced mobility. A review of progress notes dated March 28, 2024, revealed that the certified registered nurse practitioner (CRNP) assessed the resident with a chief complaint of following up on a urinary tract infection (UTI) and left hand swollen. The resident had some tenderness but was able to move her hand, no bruising noted but the area was warm and red with good capillary refill. The resident denies any injury and was afebrile (without fever). Plan of care: give a dose of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.