TUNKHANNOCK, PA - State inspectors found that Gardens At Tunkhannock nursing facility failed to follow established infection control protocols for residents with wounds and inadequately coordinated end-of-life care services during a March 2025 inspection.
Infection Control Failures Put Vulnerable Residents at Risk
Inspectors discovered significant lapses in the facility's infection prevention protocols, particularly involving a resident with an open wound who did not receive the enhanced protective measures required by both facility policy and federal guidelines. The resident, who had been diagnosed with atrial fibrillation and hypertension, developed a left heel wound that was actively draining fluid and required medical-grade honey treatment with bordered gauze dressing.
Despite the facility's own policy requiring enhanced barrier precautions for residents with wounds, staff failed to implement these critical safety measures. When inspectors observed the resident's room on March 18, 2025, they found no signage indicating special precautions were needed and no personal protective equipment readily available outside the room for staff use.
The facility's Enhanced Barrier Precautions policy, last reviewed in June 2024, specifically states that residents with wounds are at especially high risk for acquiring multi-drug-resistant organisms (MDROs). The policy mandates that gowns and gloves must be immediately available outside residents' rooms and that clear signage must indicate required protective equipment for high-contact care activities, including wound care.
Medical Significance of Infection Control Lapses
Enhanced barrier precautions serve as a critical defense against the spread of dangerous antibiotic-resistant bacteria in nursing homes. When healthcare workers provide wound care without proper protective equipment, they can unknowingly transfer harmful microorganisms between residents on their hands and clothing. This creates a particularly serious risk in congregate care settings where vulnerable elderly residents often have compromised immune systems.
Multi-drug-resistant organisms pose an especially grave threat to nursing home populations because these infections are notoriously difficult to treat and can lead to serious complications including sepsis, prolonged hospitalizations, and increased mortality rates. The Centers for Disease Control and Prevention has identified nursing homes as high-risk environments for MDRO transmission, making strict adherence to infection control protocols essential for resident safety.
Significantly, the facility only initiated the required physician orders for enhanced barrier precautions on March 20, 2025 - two days after the inspection observation and only after surveyor inquiry. The Director of Nursing confirmed during a follow-up interview that "the facility is responsible for ensuring full implementation of infection control procedures, including enhanced barrier precautions, in accordance with facility policy and nationally recognized infection control guidelines."
Hospice Care Coordination Deficiencies
The inspection also revealed failures in coordinating care between the facility and hospice services for a terminally ill resident. The resident, who had been admitted with peripheral vascular disease and type 2 diabetes, was enrolled in hospice services in October 2024 for end-stage peripheral vascular disease.
However, the resident's care plan failed to reflect any coordination of services between the facility and the hospice agency. The care plan, which was last revised in March 2025, contained no evidence of how the facility and hospice would work together to meet the resident's daily care needs or address specific requirements related to terminal care.
The Director of Nursing acknowledged during an interview that "the resident's care plan did not reflect coordination of services between the facility and the hospice agency" and confirmed there was "no documented evidence of interdisciplinary communication or coordination ensuring that hospice and facility staff were aligned in their provision of care."
Industry Standards for End-of-Life Care Coordination
Effective hospice care coordination requires detailed documentation of which services each entity will provide and how they will communicate to ensure seamless care delivery. Federal regulations mandate that nursing facilities must coordinate with hospice agencies to develop comprehensive care plans that identify the specific roles and responsibilities of each provider.
Proper coordination typically includes regular interdisciplinary team meetings, shared documentation systems, and clear protocols for managing pain and comfort measures. When coordination breaks down, residents may experience fragmented care, medication errors, or inadequate symptom management during their final months of life.
Dining Room Overcrowding Creates Safety Hazards
Inspectors also identified significant overcrowding in the facility's dining areas that compromised both resident safety and dignity during mealtimes. In the Blue Unit dining room, observers found fifteen residents in wheelchairs crowded around just five dining tables, with additional residents in reclining chairs using mobile bedside tables.
The congested conditions made it difficult for staff to move safely through the dining area, set up meal trays efficiently, and provide adequate assistance to residents who needed help eating. The overcrowding also restricted residents' ability to maneuver safely within the room, creating potential fall hazards and limiting their independence during meals.
During interviews, facility leadership acknowledged the space constraints, with the Director of Nursing stating that "due to staffing constraints, there was only one seating for each meal in the dependent resident dining rooms." Both the Director of Nursing and clinical nurse consultant confirmed that "the dining area was a tight fit during meals" and agreed that the current setup needed reassessment to ensure adequate space for residents.
Additional Issues Identified
The inspection documented several other compliance concerns, including failures in facility management responsibilities and nursing service protocols. These violations were categorized as having minimal harm or potential for actual harm but still represented departures from required standards of care.
The facility's management structure showed gaps in oversight that contributed to the policy implementation failures observed throughout the inspection. Additionally, nursing service protocols did not adequately address the coordination requirements for outside healthcare resources, including hospice services.
All violations identified during the March 2025 inspection have been documented in the facility's statement of deficiencies, and the nursing home is required to submit a plan of correction addressing each identified issue. The facility must demonstrate how it will prevent similar violations from occurring in the future and ensure compliance with all applicable health and safety regulations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardens At Tunkhannock, The from 2025-03-21 including all violations, facility responses, and corrective action plans.
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