Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of East Mountain during CMS and state inspections, most recent first.
A resident's personal funds were not returned within the required 30-day period after discharge. Financial records showed a substantial credit balance remained months after the resident left, and staff confirmed the delay was due to changes in business office management.
The facility failed to create individualized discharge plans for two residents, both cognitively intact, who expressed desires to return home. One resident discharged against medical advice, while the other sought waiver services. The facility did not update care plans to reflect these goals, as confirmed by staff interviews.
The facility failed to maintain clear hallways, with linen carts, PPE storage bins, and equipment obstructing handrails in three resident hallways. These obstructions were confirmed by the Nursing Home Administrator, acknowledging the safety hazards created for residents, staff, and visitors.
The facility failed to securely store oxygen cylinders, with seven full and five empty tanks found unsecured in the hallway. Despite having a designated storage area outside, a Maintenance Assistant stored the tanks inside for convenience, contrary to facility policy. The Nursing Home Administrator acknowledged the non-compliance.
The facility failed to provide timely pharmacy services, resulting in medication administration delays for three residents. A resident with anxiety did not receive Clonazepam due to pharmacy delivery delays. Another resident, post-hospitalization for fractures, did not receive prescribed Oxycodone for pain management, leading to increased confusion and pain. A third resident did not receive essential medications due to pharmacy delays. The facility lacked a backup emergency pharmacy and proper oversight of the medication dispensing system.
The facility failed to ensure proper oversight and management of its automated medication system, leading to missed medication doses for several residents. The lack of pharmacist supervision, system inspections, and medication accountability resulted in medication availability issues and delays in administration. The Nursing Home Administrator confirmed non-compliance with Pennsylvania code regarding pharmacy services.
A facility failed to ensure an accurate MDS assessment for a resident with dementia and oropharyngeal dysphagia. The resident had orders for enteral feeding via a PEG tube and a liquid diet for pleasure feeding, but the MDS inaccurately indicated no feeding tube. This discrepancy was confirmed by the DON.
A resident with anxiety and depression expressed suicidal thoughts and was hospitalized for psychiatric evaluation. Despite this change in condition, the facility did not refer the resident for a PASRR Level II evaluation, as confirmed by staff interviews.
A facility failed to update a resident's care plan after incidents of suicidal ideation and self-harm. Despite hospitalization and a self-inflicted injury, the care plan was not revised to address the resident's current needs. The DON confirmed the oversight.
A resident with diabetes and congestive heart failure was not placed on a restorative ambulation program as recommended by therapy, despite expressing a desire to walk more frequently. The facility's failure to implement the program was confirmed by the DON, with no evidence found in the resident's care plan or clinical record.
The facility failed to provide necessary therapeutic social services to two residents, impacting their mental and psychosocial well-being. One resident, with a history of alcoholism and suicidal ideations, expressed a desire to be discharged, but no social services addressed this conflict. Another resident, with anxiety and depression, had no documented therapeutic interventions despite a history of suicidal ideation and self-harming behaviors.
The facility failed to offer routine annual dental services to two private payor source residents. One resident, with Alzheimer's and COPD, was severely cognitively impaired, and another had Alzheimer's and muscle weakness. There was no documented evidence that their responsible parties were offered dental services in the past year, as confirmed by the DON.
A facility failed to offer routine annual dental services to a Medicaid resident with dementia and congestive heart failure. The resident's MDS assessment showed moderate cognitive impairment, and there was no documentation that the responsible party was offered dental services in the past year. This was confirmed by the DON.
The facility failed to coordinate hospice services with facility care for two residents, one with cerebral infarct and another with end-stage COPD. Their care plans lacked integration with hospice services, as confirmed by the DON, indicating a deficiency in managing hospice care coordination.
The facility failed to resolve resident complaints about cold shower water temperatures and the lack of evening snacks, despite repeated grievances voiced during Resident Council and Food Committee meetings. The NHA and DON could not provide documentation of effective measures taken to address these issues.
The facility failed to ensure that dependent residents were provided with necessary services to maintain good personal hygiene, specifically by not providing scheduled showers and neglecting personal grooming for three residents. Interviews with the DON and NHA confirmed the inconsistency in providing scheduled showers, and there was no documentation of refusals or reasons for not showering the residents as scheduled.
The facility failed to maintain a safe environment as the 100 East hallway was obstructed by various items, blocking access to handrails, and a treatment cart containing wound care equipment was found unattended and unlocked. The NHA and DON confirmed these issues, creating potential accident hazards.
The facility failed to administer oxygen as ordered and maintain sanitary oxygen delivery systems for a resident. The resident received oxygen at 4 L/min instead of the prescribed 3 L/min, and the oxygen setup was not dated. The CPAP mask was improperly stored, and the nasal cannula was re-applied without cleaning after being on the floor. Undated oxygen equipment from a discharged resident was also found in a room occupied by other residents.
The facility failed to maintain sanitary practices for food storage and service, including issues such as dust on vents, dirt on floors, missing tiles, a malfunctioning freezer door, and visibly soiled utility carts. These deficiencies increased the risk of food-borne illness.
The facility failed to conduct a significant change MDS assessment for a resident who experienced a significant decline and was placed on hospice care. Despite the resident being discontinued from hospice services, no significant change MDS assessment was completed as required.
The facility failed to ensure the MDS Assessments accurately reflected a resident's status. An annual MDS Assessment incorrectly indicated that the resident did not require a Level II PASRR process, despite previous documentation confirming the need for specialized services. This was confirmed by the social services director.
The facility failed to update the care plan for a resident with COPD after the discontinuation of Hospice services. Despite the significant change in care needs, the care plan was not revised to ensure appropriate interventions were implemented. This was confirmed by the DON.
The facility failed to develop and implement an individualized person-centered plan for a resident with dementia who exhibited severe cognitive impairment and behavioral symptoms. The care plan did not include specific behaviors or interventions, and there was no evidence of necessary care and services, including non-pharmacological approaches and specialized supports. The Nursing Home Administrator confirmed the deficiency.
Failure to Timely Return Discharged Resident's Personal Funds
Penalty
Summary
The facility failed to return the personal funds of a discharged resident within the required 30-day period. Clinical record review showed that the resident was admitted and later discharged, but a review of the resident's financial account statement revealed a significant credit balance remained months after discharge, indicating the funds had not been disbursed as required. An email from the Regional Business Office Manager confirmed that the facility's Business Office Manager had been terminated, and the refund process was delayed as a result. The Director of Nursing also confirmed that the resident's personal funds were not returned within the mandated timeframe.
Failure to Implement Individualized Discharge Plans
Penalty
Summary
The facility failed to develop and implement individualized discharge plans for two residents, Resident 252 and Resident 81, which did not reflect their discharge goals. Resident 251, who was cognitively intact with a BIMS score of 15, expressed a desire to be discharged home, as documented in a social service note. However, there was no documented evidence that the facility addressed this desire or the conflicting wish of the resident's wife for him to remain in the facility. The resident eventually discharged himself against medical advice, and the comprehensive care plan lacked any updates or revisions to reflect his discharge goals. Similarly, Resident 81, also cognitively intact with a BIMS score of 15, expressed a desire to return home with waiver services. Despite the resident's clear communication of this goal, the comprehensive care plan indicated long-term placement at the facility, with no evidence of quarterly updates or agreement from the resident on this plan. Interviews with facility staff, including the Nursing Home Administrator and the Director of Nursing, confirmed the absence of documented discharge plans that aligned with the residents' goals.
Obstructions in Hallways Create Safety Hazards
Penalty
Summary
The facility failed to maintain an environment free of accident hazards in three resident hallways, as observed during a survey. In the 200 hallway, three linen carts and a floor cleaning machine were positioned in a manner that obstructed access to handrails, which are essential for resident safety. Additionally, four linen carts were lined up against the wall in the hallway connecting the 100 and 200 hallways, further blocking the handrails. This area is significant as it includes access to the resident dining room, a high-traffic area for residents. In the 100 resident hallway, plastic storage bins containing PPE and a mechanical lift were placed in front of resident rooms, restricting access to handrails. Similarly, in the 200 hallway, additional PPE storage bins and two wheelchairs were found obstructing the handrails. The 300 hallway also had a plastic storage bin impeding access to handrails. The Nursing Home Administrator confirmed these observations, acknowledging that the placement of these items created obstructions, thus failing to ensure safe passage for residents, staff, and visitors.
Unsafe Oxygen Storage in Hallway
Penalty
Summary
The facility failed to store oxygen in a safe and secure manner, as observed during a survey. Seven full oxygen cylinders were found in a multi-tank rack on wheels, not secured to the wall or floor, positioned on the right side of the hallway. Additionally, five empty oxygen tanks were stored in a similar unsecured rack on the left side of the hallway near the exit door. Signs were posted above the tanks to designate areas for full and empty cylinders, but the storage did not comply with the facility's policy, which requires oxygen to be stored in an enclosed, secured area. Employee 1, a Maintenance Assistant, was observed refilling the oxygen storage rack with full tanks, resulting in a total of 12 full oxygen tanks stored in the unsecured hallway location. During an interview, Employee 1 stated that an enclosed, locked oxygen storage area is available outside the west hallway exit door, but he chose to store the tanks inside for the convenience of the nursing staff. The Nursing Home Administrator confirmed that storing oxygen in the hallway was not in accordance with the facility's policy.
Pharmacy Service Delays in Medication Administration
Penalty
Summary
The facility failed to ensure the timely provision of pharmacy services, resulting in delays in the administration of physician-prescribed medications for three residents. Resident 90, who was admitted with chronic obstructive pulmonary disease, dysphagia, depression, and anxiety, did not receive Clonazepam as prescribed due to a delay in pharmacy delivery. The Director of Nursing confirmed that the medication was unavailable at the facility at the time it was needed. Resident 64, admitted with dementia and congestive heart failure, experienced a fall and was hospitalized with fractures. Upon readmission, the resident had orders for Oxycodone for pain management, but the medication was not administered for several days due to unavailability. The resident exhibited increased confusion and pain, and Tylenol was given instead. The facility's emergency supply did not include Oxycodone, and the Director of Nursing confirmed the medication was not available since the resident's discharge from the hospital. Resident 201, admitted for aftercare and therapy, did not receive Diltiazem, Oxycodone-Acetaminophen, and Levothyroxine due to pharmacy delays. The facility's emergency medication supply and automated dispensing system had discrepancies in medication inventory and expiration dates. The Director of Nursing and Nursing Home Administrator acknowledged the lack of a backup emergency pharmacy and confirmed that nursing staff, rather than trained pharmacy personnel, were responsible for restocking the system without proper training. The facility failed to provide documentation of pharmacy oversight or staff training, leading to delays in essential medication administration.
Failure in Automated Medication System Management
Penalty
Summary
The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring proper oversight and management of its automated medication system as required by Pennsylvania Code Title 49, Chapter 27. The facility did not maintain pharmacist supervision, conduct necessary system inspections, or ensure proper medication accountability. This lack of oversight led to multiple instances of missed medication doses for residents, including Clonazepam for one resident, Oxycodone for another, and Diltiazem, Levothyroxine, and Oxycodone-Acetaminophen for a third resident. The facility also failed to maintain a readily retrievable audit trail and documented oversight of the automated medication system. The Pennsylvania code requires that automated medication systems be managed under the supervision of a pharmacist and include documentation of oversight activities, system inspections, and accountability for stocking and removing medications. However, the facility was unable to provide documentation verifying that the required oversight and management of the automated medication system were conducted. The Nursing Home Administrator confirmed that the facility pharmacy did not adhere to the Pennsylvania code regarding pharmacy services, and that pharmacy staff were not actively managing the system, contributing to medication availability issues and delays in administration.
Inaccurate MDS Assessment for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure that the Minimum Data Set Assessment (MDS) accurately reflected the status of a resident, identified as Resident 25. This deficiency was identified during a review of clinical records and the Resident Assessment Instrument (RAI), as well as through staff interviews. Resident 25 was admitted with diagnoses including dementia and oropharyngeal dysphagia. The resident had a physician order for Nutren 1.5 via a PEG tube for enteral feeding and a full liquid nectar/mildly thick consistency diet for pleasure feeding. However, the quarterly MDS assessment inaccurately indicated that the resident did not have a feeding tube. The inaccuracy in the MDS assessment was confirmed during an interview with the director of nursing. This discrepancy highlights a failure in the facility's assessment process, as the MDS did not accurately capture the resident's nutritional approaches, specifically the use of a feeding tube. The failure to accurately document the resident's status in the MDS could potentially impact the planning and delivery of appropriate care for the resident.
Failure to Refer Resident for PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with newly evident serious mental disorder for a Preadmission Screening and Resident Review (PASRR) Level II evaluation. The resident, who was admitted with diagnoses including anxiety and depression, initially screened negative for serious mental illness on the PASRR Level I form. However, a nurse's note later documented that the resident expressed suicidal thoughts and was subsequently transferred to a hospital for psychiatric evaluation. Despite this significant change in the resident's mental health condition, the facility did not report the inpatient stay for suicidal ideation to the state's mental health authority for a PASRR Level II evaluation. The deficiency was confirmed during interviews with the consultant social worker and the Nursing Home Administrator, who acknowledged the facility's responsibility to ensure residents with newly evident serious mental disorders are referred for PASRR Level II evaluations. The failure to report and refer the resident for further evaluation after the hospital stay indicates a lapse in the facility's compliance with federal and state requirements for the PASRR process.
Failure to Update Care Plan for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to reflect the resident's current needs and services. The resident, who was admitted with diagnoses including depression and anxiety, expressed suicidal thoughts and was transferred to the hospital for psychiatric evaluation. Despite being readmitted to the facility with a diagnosis of suicidal ideation, the care plan was not updated to address these issues. On a later date, the resident was found with self-inflicted lacerations and admitted to using a knife, which was found at the bedside. The care plan, which had not been revised since several months prior, did not include updated interventions to address the resident's suicidal statements and self-harming behavior. The Director of Nursing confirmed that the facility did not review and revise the care plan to accurately reflect the resident's current status, risks, and needs.
Failure to Implement Restorative Ambulation Program
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for a resident, identified as Resident 85. The facility's Restorative Nursing Services Policy, last reviewed in January 2025, outlines that a restorative nursing program should assist residents in achieving or maintaining their optimal functional level. However, upon review, it was found that Resident 85, who was admitted with diagnoses including diabetes and congestive heart failure, was not placed on a restorative ambulation program as recommended by therapy. The resident, who was moderately cognitively impaired, expressed a desire to walk more frequently with assistance, noting that she felt weaker when not engaged in regular walking activities. The clinical record review revealed that Resident 85 was discharged from physical therapy on February 28, 2025, with a recommendation for a restorative ambulation program to maintain her current level of functioning. Despite this recommendation, there was no evidence in the resident's care plan or clinical record that such a program was implemented. An interview with the director of nursing confirmed the lack of documented evidence for the implementation of the restorative ambulation program, which was necessary to maintain the resident's mobility as recommended by therapy.
Failure to Provide Therapeutic Social Services
Penalty
Summary
The facility failed to provide necessary therapeutic social services to two residents, leading to deficiencies in their mental and psychosocial well-being. Resident 251, who was admitted with diagnoses including alcoholism and a history of suicidal ideations, expressed a strong desire to be discharged home, which was opposed by his wife. Despite the resident's frequent expressions of frustration and agitation about wanting to leave, there was no documented evidence that social services addressed the conflict regarding discharge planning. The resident's care plan lacked interventions related to his alcoholism, suicidal ideations, or concerns about discharge planning, and there was no documentation of therapeutic social services provided to support him. Eventually, the resident signed out Against Medical Advice. Resident 81, admitted with anxiety and depression, had a documented history of suicidal ideation and self-harming behaviors, resulting in multiple hospitalizations for psychiatric evaluation. Despite these ongoing concerns, there was no evidence that the facility's social services provided appropriate therapeutic interventions to address the resident's mental health needs. A social services note mentioned the possibility of transferring the resident to another facility, but there was no documentation of any actions taken regarding alternate placement options. The Director of Nursing confirmed the lack of documented social services interventions to support Resident 81's psychosocial well-being.
Failure to Offer Routine Dental Services to Residents
Penalty
Summary
The facility failed to offer routine annual dental services to two private payor source residents, identified as Residents 60 and 39, out of four residents sampled for dental services. Resident 60, admitted with Alzheimer's disease and COPD, was severely cognitively impaired according to the Minimum Data Set assessment. There was no documented evidence that Resident 60's responsible party was offered routine annual dental services in the past year. Similarly, Resident 39, admitted with Alzheimer's disease and muscle weakness, also had no documented evidence of being offered routine annual dental services. An interview with the Director of Nursing confirmed that the responsible parties for both residents had not been consulted regarding dental services in the past year.
Failure to Offer Routine Dental Services to a Resident
Penalty
Summary
The facility failed to offer routine annual dental services to a Medicaid payor source resident, identified as Resident 64, who was admitted with diagnoses including dementia and congestive heart failure. The resident's Annual Minimum Data Set assessment indicated moderate cognitive impairment. Upon review of the clinical record, there was no documented evidence that the resident's responsible party was offered dental services in the past year. This was confirmed during an interview with the Director of Nursing, who acknowledged that the responsible party had not been consulted regarding dental services for the resident.
Lack of Coordination in Hospice Services for Residents
Penalty
Summary
The facility failed to ensure proper coordination of hospice services with facility services for two residents receiving hospice care. Resident 54, who was admitted with a diagnosis of cerebral infarct, was enrolled in hospice services for the management of this terminal illness. However, a review of the resident's plan of care revealed no evidence of integration with hospice services to demonstrate coordination of care and services to meet the resident's needs related to their terminal illness on a daily basis. Similarly, Resident 61, admitted with diagnoses including dementia, chronic obstructive pulmonary disease (COPD), and anxiety, was receiving hospice services for end-stage COPD. The review of this resident's care plan also showed a lack of coordination between the facility and the hospice agency in addressing the resident's daily care needs and specific needs related to their terminal diagnosis. The Director of Nursing confirmed that the care plans for both residents were not integrated or coordinated with hospice services, indicating a deficiency in the facility's management of hospice care coordination.
Failure to Address Resident Complaints
Penalty
Summary
The facility failed to address and resolve resident complaints and grievances in a timely manner, as evidenced by the review of the facility's policy, meeting minutes, and resident and staff interviews. Residents expressed concerns about cold shower water temperatures and the lack of evening snacks during Resident Council and Food Committee meetings from December 2023 through March 2024. Despite these repeated complaints, the facility did not provide documented evidence that they had resolved these issues or followed up with the residents to ensure their concerns were addressed. During a group meeting on April 10, 2024, four alert and oriented residents confirmed that the issues with cold shower water temperatures and the absence of evening snacks persisted. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide documentation showing that the facility had taken effective measures to resolve these complaints. This failure to address resident grievances violated the residents' rights and the facility's own grievance policy.
Failure to Provide Scheduled Showers and Personal Grooming
Penalty
Summary
The facility failed to ensure that dependent residents were provided with the necessary services to maintain good personal hygiene, specifically by not providing showers as scheduled and neglecting personal grooming for three of 23 residents sampled. Resident 7, who has multiple sclerosis and requires extensive assistance with ADLs, did not receive a shower for three months, and there was no documentation of any refusals or reasons for this. The resident was observed with long, dirty fingernails, oily hair, and an unshaven face, indicating a lack of personal grooming. Resident 47, who requires substantial assistance with ADLs and is cognitively intact, was only showered twice in three months and given a bed bath five times, with no documented evidence of refusals or reasons for not showering as scheduled. Resident 5, who has severe cognitive impairment and requires extensive assistance with ADLs, was only showered twice in two months, with no documentation of refusals or reasons for this. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility has not been able to consistently provide residents' showers as scheduled. The facility's policy requires that if a resident refuses a shower, a bed bath should be offered and provided as per the resident's preference, but there was no evidence of this being done. The DON and NHA acknowledged that it is the facility's responsibility to assist residents with activities of daily living to maintain good personal grooming and hygiene for residents dependent on staff for assistance.
Obstructed Hallways and Unlocked Treatment Cart
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards on the East and [NAME] Hallways. Observations on April 9 and April 10, 2024, revealed that the 100 East hallway was obstructed by 3 rollator walkers, 5 wheelchairs, a resident room armchair, a stool, and a large linen cart, blocking access to the handrails on the right side of the corridor. Multiple residents were observed self-propelling in wheelchairs in the hallway. The Nursing Home Administrator confirmed that the handrails were obstructed, impeding residents' access to assist with ambulation and mobility. Additionally, on April 10, 2024, a treatment cart labeled [NAME] was found unattended and unlocked in the main hallway, containing wound care equipment including scissors and hydrogen peroxide. The Director of Nursing confirmed that the cart should have been locked to prevent resident access, creating a potential accident hazard.
Failure to Administer Oxygen as Ordered and Maintain Sanitary Equipment
Penalty
Summary
The facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for Resident 47. The resident was observed receiving humidified oxygen therapy at 4 liters per minute (L/min) via nasal cannula, contrary to the physician's order of 3 L/min. Additionally, the oxygen setup, including the nasal cannula tubing and humidification bottle, was not dated. The resident's CPAP mask was improperly stored in a nightstand drawer and on top of a box containing food, rather than on a clean surface or in a bag as per facility policy. Furthermore, the nasal cannula was found on the floor and was re-applied to the resident's face without being cleaned or changed, and the oxygen concentrator was set at 4 L/min instead of the prescribed 3 L/min. Another observation revealed undated oxygen equipment in a room occupied by other residents, which was confirmed to be from a discharged resident and not removed from the room. Interviews with the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the physician's order for supplemental oxygen was not followed for Resident 47 and that oxygen equipment should be kept clean, stored properly, and dated when changed. The DON also confirmed that masks and nasal cannula/CPAP equipment should be placed in a bag when not in use. The facility's failure to adhere to these protocols resulted in deficiencies in the administration and maintenance of respiratory care for Resident 47.
Failure to Maintain Sanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During an initial tour of the food and nutrition services department, several sanitation concerns were observed. These included a thick layer of dust on the fins of the wall vent next to the handwashing sink, a build-up of dirt and debris on the perimeter area of the floor throughout the kitchen, and two missing floor tiles in the walk-in refrigerator. Additionally, the door of the walk-in freezer did not fully latch, and there were multiple brownish/blackish colored splatters on the ceiling in the dishroom. A missing tile from the floor molding at the entrance to the dishroom and a build-up of a blackish substance on the wall behind the garbage disposal were also noted. Two wooden utility carts in the kitchen area were visibly soiled and in need of cleaning. Interviews with the foodservice director confirmed that the food and nutrition services department is expected to maintain acceptable practices for food storage and sanitation. The foodservice director acknowledged that the door of the walk-in freezer had not been consistently latching for a few weeks and that a work order for repair had been completed. The administrator confirmed that a new walk-in freezer door was needed and that the order was in process, with an estimated lead time of six to eight weeks for replacement. These deficiencies indicate a failure to adhere to food safety and inspection standards, potentially leading to contamination and microbial growth in food.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced a significant decline in condition and was placed on hospice care. The resident was enrolled in hospice care on January 13, 2023, and later discontinued from hospice services on February 25, 2024. Despite these significant changes in the resident's condition, there was no documented evidence that a significant change MDS assessment was completed as required by federal regulations. An interview with the Director of Nursing (DON) confirmed that the resident was discontinued from hospice services on February 25, 2024, and that a comprehensive significant change MDS assessment was not completed. This failure to conduct the required assessment was identified during a review of the clinical record and the Resident Assessment Instrument (RAI) User's Manual, which mandates that a significant change MDS assessment be conducted within 14 days of the determination of a significant change in the resident's condition.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, the annual MDS Assessment for a resident dated June 23, 2023, incorrectly indicated that the resident did not require a Level II Preadmission Screening and Resident Review (PASRR) process. However, a review of the resident's clinical record revealed that a Level I PASRR completed on June 1, 2017, indicated the resident met the criteria for a Level II PASRR. Additionally, a letter of determination dated June 8, 2017, confirmed the resident required specialized services. This discrepancy was confirmed by the social services director during an interview on April 12, 2024.
Failure to Update Care Plan After Discontinuation of Hospice Services
Penalty
Summary
The facility failed to revise and update the comprehensive care plan for a resident after the discontinuation of Hospice services. The resident, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and was receiving Hospice services due to end-stage COPD, had their Hospice services discontinued. Despite this significant change in the resident's care needs, the facility did not update the care plan to reflect the discontinuation of Hospice services. This failure was confirmed during an interview with the director of nursing, who acknowledged that the care plan had not been reviewed and revised to ensure appropriate interventions were incorporated and implemented by the staff.
Failure to Develop Individualized Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement an effective individualized person-centered plan to address a resident's dementia-related behavioral symptoms. Resident 34, who was admitted with a diagnosis of dementia with agitation, exhibited severe cognitive impairment and displayed physical and verbal behavioral symptoms such as hitting, kicking, pushing, scratching, threatening, screaming, and cursing. Despite these behaviors being documented in the resident's clinical record and progress notes, the resident's care plan did not identify specific behaviors or interventions designed for staff to address these behaviors. The facility did not provide evidence of individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests. There was no indication that the facility provided necessary care and services, including interdisciplinary non-pharmacological approaches, purposeful and meaningful activities, or specialized services and supports such as specialized activities, nutrition, and environmental modifications. An interview with the Nursing Home Administrator confirmed the lack of an individualized person-centered plan for managing the resident's dementia-related behaviors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wilkes-barre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heinz Transitional Rehabilitation Unit | 2.5 mi | — | 2 | 0 |
| Wesley Village | 2.5 mi | — | 9 | 0 |
| Riverstreet Manor | 3.2 mi | — | 23 | 0 |
| Third Avenue Health & Rehab Center | 3.5 mi | — | 13 | 0 |
| Embassy Of Wyoming Valley | 3.6 mi | — | 31 | 0 |
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