Federal inspectors found Embassy of Wyoming Valley failed to follow basic infection control procedures designed to protect some of its most vulnerable residents. The violations occurred despite the facility having written policies requiring enhanced safety measures for residents with medical devices.
Resident 38 needed special protection because of a gastrostomy tube that delivers food and medication directly to the stomach. The resident, who has cerebral palsy and difficulty swallowing, was admitted with a physician's order from January 14 requiring enhanced barrier precautions.
The precautions were never implemented.
Inspectors found no warning signs posted outside the resident's room during observations on March 12 and March 13. The facility's own policy, last reviewed February 19, requires clear signage indicating required personal protective equipment and high-contact care activities that need gowns and gloves.
A Licensed Practical Nurse and nurse aide confirmed during interviews March 13 that no enhanced barrier precautions had been put in place for Resident 38. The resident remained without the required protection for nearly two months after the doctor's order.
The facility's policy states that residents with wounds and indwelling medical devices "are especially high risk for both the acquisition of and colonization with" multi-drug-resistant organisms. Enhanced barrier precautions expand the use of gowns and gloves during activities that create opportunities for dangerous bacteria to transfer to staff hands and clothing.
Clean towels designated for resident use were stored inside sinks in the Third Floor shower room. Inspectors observed the contaminated storage on March 11 at 7:30 PM and again the next morning at 10:30 AM in the presence of the Director of Nursing.
The nursing director acknowledged during the inspection that towels should not be stored in sinks because of contamination risks. She confirmed the facility was responsible for ensuring proper storage of resident linens.
Resident 36 faced a different infection control failure. The resident was admitted with bladder dysfunction and an enlarged prostate that required a Foley catheter to drain urine into a collection bag.
On March 11 at 8:25 PM, inspectors found the resident resting in bed with the urine collection bag lying on its side directly on the floor. Two days later at 8:25 AM, the bag remained in direct contact with the floor.
The Infection Preventionist admitted during a March 14 interview that the facility failed to maintain the catheter properly to prevent urinary tract infections. The specialist acknowledged the facility had not followed appropriate infection control techniques for a resident with an indwelling catheter.
Foley catheters create a direct pathway for bacteria to enter the bladder. Allowing the drainage bag to touch the floor increases contamination risk and the potential for serious infections that can spread to the kidneys or bloodstream.
The violations occurred across multiple areas of the facility and involved different types of medical devices. Resident 38's feeding tube required one set of precautions that went unimplemented. Resident 36's catheter needed different protections that were also ignored.
Both residents had conditions that made them particularly susceptible to infections. Resident 38's cerebral palsy and swallowing difficulties, combined with the feeding tube, created multiple vulnerability points. Resident 36's bladder and prostate problems, along with the catheter, presented ongoing infection risks.
The facility's policies acknowledged these dangers. The enhanced barrier precautions policy specifically identified residents with indwelling medical devices as high-risk. Yet staff failed to follow the written procedures designed to protect these vulnerable residents.
The nursing director's admission that towels belonged elsewhere than in sinks demonstrated staff awareness of proper infection control principles. The Infection Preventionist's acknowledgment of catheter care failures showed understanding of required techniques.
Knowledge of proper procedures made the violations more troubling. Staff knew what should be done but failed to implement the protections that could prevent serious infections in residents who were already medically fragile.
The inspection found the facility's infection prevention and control program was not being properly implemented despite having appropriate written policies. The gap between policy and practice left residents exposed to preventable risks.
Resident 38 spent weeks without the enhanced precautions ordered by the physician. Resident 36's urine bag remained on the floor through multiple nursing shifts. Clean towels sat in contaminated sinks while residents needed them for personal care.
Each violation represented a failure to protect residents who depended on staff to follow infection control procedures they could not implement themselves. The residents' medical conditions made them unable to advocate for the safety measures they needed.
The facility received citations for failing to provide and implement an infection prevention and control program. Inspectors classified the violations as causing minimal harm or potential for actual harm to some residents.
Embassy of Wyoming Valley must now develop plans to correct the deficiencies and demonstrate compliance with infection control requirements designed to protect residents with medical devices and other risk factors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Embassy of Wyoming Valley from 2025-03-14 including all violations, facility responses, and corrective action plans.
