Embassy of Wyoming Valley: Wound Care Failure - PA
The resident, identified in inspection records as Resident 57, had been receiving Bacitracin External Ointment as part of a wound treatment routine. On January 20, 2025, a Certified Registered Nurse Practitioner conducted wound rounds, reviewed the area, and issued a new order discontinuing the treatment. The note recorded that the resident's representative was informed of the change.
Nobody told the staff doing the treating.
Treatment Administration Records reviewed by inspectors showed that applications of Bacitracin continued twice daily from January 20, 2025, through March 12, 2025. That is 52 days of a treatment that a clinician had formally ended, applied to skin that had nothing wrong with it.
When inspectors observed Resident 57 on the morning of March 13, 2025, at 8:00 AM, with a licensed practical nurse present, there were no abrasions anywhere on the scalp. The wound the ointment had been treating was gone. It had been gone since at least January.
Later that morning, the facility's Regional Nurse Consultant confirmed what the records showed. The abrasion had healed. The treatment should have stopped on January 20. The consultant did not dispute the timeline.
The violation was cited at a level of minimal harm or potential for actual harm, and inspectors noted that some residents were affected. The inspection was completed March 14, 2025.
What the records describe is a breakdown somewhere between the clinician who wrote the discontinuation order and the staff responsible for carrying it out. The nurse practitioner did her job. She examined the wound, made a clinical decision, documented it, and notified the family. The order existed in the chart. The representative had been told. And then, for the next seven and a half weeks, staff opened a tube of ointment and applied it to healed skin anyway, twice a day, because that is what the treatment record still told them to do.
Bacitracin is a topical antibiotic. Applying it to intact skin is not, on its own, a catastrophic act. But the failure documented here is not really about ointment. It is about whether a clinical order, once written, actually reaches the people responsible for carrying it out, and whether anyone checks. In this case, the answer to both questions was no, for nearly two months.
The inspection report does not explain how the error went undetected across 52 days of twice-daily treatments, across multiple staff members who would have been drawing from the same treatment record, across whatever supervisory or medication review processes the facility uses. The Regional Nurse Consultant, when asked, confirmed the mistake and moved on.
Resident 57, when inspectors arrived, had a clean scalp and no sign of the original injury. The harm in the record is categorized as minimal. What is harder to categorize is what it means that a formal clinical order, documented and communicated to the family, had no discernible effect on what staff actually did for the better part of two months.
Embassy of Wyoming Valley is located at 50 North Pennsylvania Avenue in Wilkes-Barre. The inspection was conducted by the Pennsylvania Department of Health on behalf of the Centers for Medicare and Medicaid Services.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
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Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 6, 2026 · Our methodology
EMBASSY OF WYOMING VALLEY in WILKES BARRE, PA was cited for violations during a health inspection on March 14, 2025.
The resident, identified in inspection records as Resident 57, had been receiving Bacitracin External Ointment as part of a wound treatment routine.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.