WILKES-BARRE, PA - Federal inspectors found that The Gardens At East Mountain nursing facility failed to properly coordinate hospice services with facility care for terminally ill residents, leaving vulnerable patients without integrated end-of-life support during their final stages of serious medical conditions.
Critical Care Coordination Failures Documented
During a March 2025 inspection, Centers for Medicare & Medicaid Services surveyors discovered that the 101 East Mountain Drive facility had not established proper coordination between nursing home services and hospice providers for residents receiving end-of-life care. The deficiency affected residents with terminal diagnoses including stroke and end-stage chronic obstructive pulmonary disease.
The inspection revealed that two residents receiving hospice services lacked integrated care plans that would ensure seamless coordination between the facility's daily nursing care and specialized hospice services designed to manage terminal illnesses and provide comfort care.
Resident 54, who had been admitted to hospice services in February 2025 following a cerebral infarct (stroke), had no evidence in their care plan showing integration with hospice services. Similarly, Resident 61, who had been receiving hospice care since October 2024 for end-stage chronic obstructive pulmonary disease, also lacked a coordinated care approach between facility staff and hospice providers.
Medical Significance of Coordinated End-of-Life Care
Proper coordination between nursing facilities and hospice services represents a critical component of quality end-of-life care. When patients reach terminal stages of conditions like stroke or chronic obstructive pulmonary disease, their care needs become increasingly complex and require specialized attention that goes beyond standard nursing home services.
Hospice care focuses on comfort, pain management, and quality of life rather than curative treatments. This approach requires careful coordination with facility staff to ensure that daily care activities, medication management, and medical interventions align with the patient's comfort-focused goals. Without this coordination, patients may receive conflicting care approaches or experience gaps in their pain management and comfort measures.
For stroke patients like Resident 54, terminal care typically involves managing complications such as difficulty swallowing, mobility limitations, and potential cognitive changes. Hospice services provide specialized expertise in addressing these end-of-life challenges while maintaining the patient's dignity and comfort.
Patients with end-stage chronic obstructive pulmonary disease, like Resident 61, often experience breathing difficulties, fatigue, and anxiety related to their declining respiratory function. Coordinated care ensures that both facility nursing staff and hospice professionals work together to manage these symptoms effectively and provide appropriate respiratory support and comfort measures.
Regulatory Requirements for Hospice Coordination
Federal regulations require nursing facilities to coordinate with hospice agencies to develop unified care plans that clearly identify which provider is responsible for specific services and functions. This coordination must address both the resident's general daily care needs and the specialized requirements related to their terminal diagnosis.
The regulation mandates that facilities demonstrate active collaboration in developing coordinated care plans rather than simply allowing hospice services to operate independently within the facility. This includes ensuring that nursing staff understand their role in supporting hospice goals and that hospice providers are aware of the facility's daily care routines and capabilities.
Effective coordination typically involves regular communication between facility nursing staff and hospice teams, shared documentation systems that allow both providers to track the patient's condition and care responses, and clear protocols for managing medical emergencies or changes in the patient's condition.
Director of Nursing Acknowledges Coordination Gaps
During the inspection, the facility's Director of Nursing confirmed that the residents' care plans were not integrated or coordinated with hospice services for both affected residents. This acknowledgment highlighted a systemic issue in the facility's approach to managing hospice relationships rather than isolated oversights.
The lack of coordination meant that facility staff and hospice providers were potentially working with different care objectives and protocols, creating confusion about treatment priorities and potentially compromising the quality of end-of-life care these vulnerable residents received.
Impact on Quality End-of-Life Care
When nursing facilities fail to coordinate properly with hospice services, several serious consequences can occur. Residents may experience inadequate pain management if facility staff are not fully informed about hospice pain control protocols. Additionally, family members may receive conflicting information about their loved one's condition and care approach from different providers.
The absence of coordinated care plans also means that changes in a resident's condition may not be communicated effectively between providers, potentially leading to inappropriate interventions or missed opportunities to adjust comfort measures. This lack of communication is particularly concerning for residents with progressive conditions where rapid changes in status are common.
Additional Issues Identified
The inspection also documented violations related to pharmacy services and nursing services management, indicating broader concerns about the facility's compliance with healthcare regulations and standards for resident care coordination.
The deficiencies were classified as having "minimal harm or potential for actual harm" and affected "few" residents, suggesting that while the violations were serious, they had not yet resulted in documented injury to residents at the time of the inspection.
The facility operates under Pennsylvania healthcare regulations that require comprehensive coordination of all medical services, including specialized hospice care, to ensure residents receive appropriate and well-coordinated healthcare throughout their stay, particularly during terminal illness phases.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardens At East Mountain, The from 2025-03-07 including all violations, facility responses, and corrective action plans.
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