Gardens at East Mountain: Hospice Care Failures - PA
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.
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.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
EMBASSY OF EAST MOUNTAIN in WILKES-BARRE, PA was cited for violations during a health inspection on March 7, 2025.
The deficiency affected residents with terminal diagnoses including stroke and end-stage chronic obstructive pulmonary disease.
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.