Embassy Of Wyoming Valley
EMBASSY OF WYOMING VALLEY in WILKES BARRE, PA — inspection on March 14, 2025.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
see the cute guys outside?
windows were cloudy, reducing visibility.
Interview with Resident 7, at the time of the observation,
Interview with the Nursing Home Administrator and Director of Nursing on March 14, 2025 at approximately 11:00 PM confirmed the facility's environment should be kept in good repair and maintained in a clean and homelike manner. 28 Pa Code 201.18(e)(2.1) Management
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
Review of the Occupational Therapy (OT) Discharge summary dated [DATE], indicated that Resident 1 achieved the long-term goal of increased time out of bed/out of the room in the wheelchair with the use of a chest harness and slider belt for 6 hours in order to enhance comfort.
Discharge recommendations included OOB in tilt-in-space wheelchair with chest harness and padded between the leg belt.
Review of clinical record for Resident 1 revealed no evidence that the resident was evaluated for the need and use of physical restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom.
There was no physician documentation regarding the medical necessity for the chest harness, seatbelt, and slider belt.
There was no documented evidence that the facility obtained informed consent prior to the use of restraints.
There was no documented consent available in the clinical record.
Interview with the Director of Rehabilitation (DOR) on March 13, 2025, at 12:50 PM revealed the facility had not identified the chest harness and slider belt as a physical restraint.
The DOR reported that staff should not be using the standard seatbelt on the wheelchair.
The DOR confirmed that the facility failed to conduct a restraint evaluation as indicated in the facility's Restraint Free Environment policy.
The DOR was unable to provide documented evidence that the facility obtained informed consent from the resident's responsible party prior to the use of the physical restraints as indicated in the Use of Restraints policy. 28 Pa.
Code 201.29 (a) Resident rights 28 Pa.
Code 211.10 (a) Resident care policies 28 Pa.
Code 211.8 (c.1)(e)(f)Use of restraints 28 Pa.
Code 211.12 (d)(5) Nursing services
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
ombudsman, before transfer or discharge, including appeal rights.
minimal harm NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility-initiated transfer notices and staff interview, it was determined that
hospital for one resident out of the 21 residents sampled. (Resident 60).
Findings include:: A review of Resident 60's clinical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (irregular heartbeat) and Chronic Obstructive Pulmonary Disease (COPD a progressive lung disease characterized by chronic respiratory symptoms and airflow limitations).
A review of the clinical record revealed that Resident 60 was transferred to the hospital on June 28,2024 and was readmitted to the facility on [DATE].
A review of the clinical record failed to reveal documented evidence the facility provided the representative of the Office of the State Long Term Care Ombudsman with a written notice of the facility-initiated transfer and reason for the transfer on June 28,2024 An interview with the Nursing Home Administrator (NHA) on March 14,2025, at 11:45 a.m., confirmed the facility had no documented evidence indicating the representative of the Office of the State Long Term Care Ombudsman was informed of the transfer in writing. 28 Pa.
Code 201.14(a) Responsibility of licensee.
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
resident?s bed in cases of transfer to a hospital or therapeutic leave.
minimal harm Based on a review of clinical records and staff interview it was determined the facility failed to provide residents or their representatives with written information of the facility's bed hold policy
Findings include: A review of Resident 39's clinical record revealed the resident was transferred to the hospital on January 16,2025 and returned to the facility on January 21,2025.
There was no documented evidence the facility provided this resident and/or their representatives written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) at the time of transfer.
Interview with the Nursing Home Administrator on March 13,2025 at 2:24 PM confirmed the facility was unable to provide documented evidence of the provision of a written notice of the facility's bed hold policy upon hospital transfer. 28 Pa Code 201.18 (b)(3) Management 28 Pa.
Code 201.14(a) Responsibility of licensee 28 Pa.
Code 211.12(d)(2)(3)(5) Nursing services
During an interview on March 13, 2025, at 8:30 AM, the Regional Nurse Consultant confirmed the abrasion on Resident 57's scalp had healed and acknowledged the treatment should have been discontinued on January 20, 2025. 28 Pa.
Code 211.5 (f)(i)(ii)(iii)(ix) Medical Records 28 Pa.
Code 211.12 (c)(d)(1)(3)(5) Nursing Services
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
PICC line length had been followed.
28 Pa.
Code 211.12 (c)(d)(1)(3)(5) Nursing services.
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
confirmed the absence of physician orders and a care plan that included planned care and emergency
non-compliance.
28 Pa.
Code 211.12 (d)(1)(3)(5) Nursing services.
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
proper oversight of the medication dispensing system.
28 Pa.
Code 211.12 (d)(1)(3)(5) Nursing Services.
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
Based on review of select facility policy, observation, and staff interview it was determined the
units.
Findings include: Review of the facility Medication Storage policy last reviewed February 19, 2025, indicated that medications and biologicals (medications that come from living organisms) are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.
Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a secured refrigerator with a thermometer to allow temperature monitoring.
An observation of the medication refrigerator located in the nurse's station on the Third Floor Nursing Unit on March 11, 2025, at 7:20 PM in the presence of employee 3 (registered nurse) revealed that various medications which required refrigerator were being stored in the refrigerator.
The thermometer in the refrigerator read 50 degrees Fahrenheit.
A second observation of the medication refrigerator located in the nurse's station on the Third Floor Nursing Unit on March 11, 2025, at 8:10 PM revealed the refrigerator temperature remained at 50 degrees Fahrenheit.
The medications had been removed from the refrigerator.
Interview with employee 3 (registered nurse) at this time confirmed the director of nursing (DON) was informed of the concern with the refrigerator and the medications were temporarily moved to the refrigerator on the Second Floor Nursing Unit.
Interview with the nursing home administrator (NHA) on March 11, 2025, at approximately 8:30 PM confirmed the refrigerator on the Third Floor Nursing Unit was not maintaining an acceptable temperature and was being replaced.
An observation of the medication room on the Second Floor Nursing Unit on March 13, 2025, at 11:00 AM in the presence of Employee 2. It was noted the medication refrigerator contained multiple unopened Ozempic pens (medication used to help lower blood sugar).
However, there was no thermometer inside the refrigerator and no temperature monitoring log was available for review to verify the medications were being stored at the appropriate temperature.
Employee 2 stated that a thermometer should be present in the medication refrigerator and that a temperature monitoring log should be maintained to ensure licensed staff are monitoring the internal refrigerator temperature.
An interview with the regional nurse consultant on March 13, 2025, at approximately 12:00 PM confirmed that all medication refrigerators were to have a thermometer present inside each refrigerator and licensed staff were to monitor medication refrigerator temperatures at least daily and record the date and temperature on a temperature monitoring log.
The regional nurse consultant also indicated that medications which required refrigeration were to be stored at an acceptable temperature. 28 Pa Code 211.12(d)(1) Nursing services. 28 Pa Code 211.9(a)(1)(k) Pharmacy services
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
During initial tour of the food and nutrition services department on March 11, 2025, at 6:20 PM the food and nutrition services director (FSD) stated that he had been the FSD since January 21, 2025.
The FSD stated that he had a culinary background but did not yet have a certification to meet the requirements for a qualified foodservice director based on current federal regulation.
The FSD stated that he does visit residents for food preferences.
The FSD further stated the full-time registered dietitian (RD) had recently quit, and the current RD works remotely and was available via e-mail and telephone.
Interview with the nursing home administrator (NHA) on March 12, 2025, at approximately 9:00 AM confirmed that the full-time RD's last day of employment was on March 7, 2025.
The NHA confirmed the current RD worked remotely on a part-time basis.
The NHA confirmed the facility failed to provide documented evidence the facility employed a full-time qualified food service director in the absence of a full-time qualified dietitian.
The NHA failed to provide documented evidence the services of the remote RD included face to face interactions with residents to ensure appropriate nutritional oversight for residents in the facility.
The NHA failed to provide documented evidence the current remote RD was scheduled to provide frequently scheduled consultations to the FSD. 28 Pa Code 201.18 (e)(1)(6) Management.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
Based on the provided information during the survey ending March 14, 2025, the facility failed to specifically ensure the oversight and management of the automated medication system as required by Pennsylvania Code Title 49, Chapter 27, which mandates pharmacist supervision, system inspections, and proper medication accountability.
The maintenance of a readily retrievable audit trail and documented oversight of the automated medication system.
The Pennsylvania code Title 49 require that automated medication systems be managed under the supervision of a pharmacist and include documentation of oversight activities, system inspections, and accountability for stocking and removing medications.
However, the facility failed to provide documentation verifying the required oversight and management of the automated medication system were conducted.
During an interview on March 14, 2025, at 11:00 AM, the Regional Nurse Consultant failed to provide documented evidence the contracted pharmacy was adhering to the Pennsylvania code regarding pharmacy services.
The Regional Nurse Consultant failed to provide documented evidence regarding oversight and management of the system by contracted pharmacy staff.
Refer F-F755 28 Pa.
Code 201.18 (b)(3)(e)(1) Management. 28 Pa.
Code 211.9 (a)(l)(d)(k)(l)(1)(2)(3) Pharmacy Services. 28 Pa.
Code 211.12 (d)(3)(5) Nursing Services.
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
Review of nursing documentation dated January 9, 2025, at 3:44 PM revealed Resident 36 was admitted to the facility with a Foley catheter (a flexible tube inserted through the urinary opening and into the bladder.
The device drains the urine into a drainage bag).
An observation on March 11, 2025, at 8:25 PM, revealed that Resident 36 was resting in bed, and the urine collection bag from the resident's Foley catheter was lying on its side, directly on the floor.
A subsequent observation on March 13, 2025, at 8:25 AM, again revealed that the urine collection bag was in direct contact with the floor, creating an increased risk for contamination and infection.
An interview with the Infection Preventionist on March 14, 2025, at 11:00 AM, confirmed the facility failed to maintain Resident 36's Foley catheter in a manner that would prevent the potential for urinary tract infections (UTIs).
The Infection Preventionist further acknowledged the facility failed to uphold appropriate infection control techniques for a resident with an indwelling Foley catheter. 28 Pa.
Code 211.10 (a)(d) Resident care policies. 28 Pa.
Code 211.12 (c )(d)(1)(5) Nursing services.
395456 03/14/2025
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
Review of nursing documentation dated January 9, 2025, at 3:44 PM revealed Resident 36 was admitted to the facility with a Foley catheter (a flexible tube inserted through the urinary opening and into the bladder.
The device drains the urine into a drainage bag).
An observation on March 11, 2025, at 8:25 PM, revealed that Resident 36 was resting in bed, and the urine collection bag from the resident's Foley catheter was lying on its side, directly on the floor.
A subsequent observation on March 13, 2025, at 8:25 AM, again revealed that the urine collection bag was in direct contact with the floor, creating an increased risk for contamination and infection.
An interview with the Infection Preventionist on March 14, 2025, at 11:00 AM, confirmed the facility failed to maintain Resident 36's Foley catheter in a manner that would prevent the potential for urinary tract infections (UTIs).
The Infection Preventionist further acknowledged the facility failed to uphold appropriate infection control techniques for a resident with an indwelling Foley catheter. 28 Pa.
Code 211.10 (a)(d) Resident care policies.
28 Pa.
Code 211.12 (c )(d)(1)(5) Nursing services.
395456
During initial tour of the food and nutrition services department on March 11, 2025, at 6:20 PM the food and nutrition services director (FSD) stated that he had been the FSD since January 21, 2025.
The FSD stated that he had a culinary background but did not yet have a certification to meet the requirements for a qualified foodservice director based on current federal regulation.
The FSD stated that he does visit residents for food preferences.
The FSD further stated the full-time registered dietitian (RD) had recently quit, and the current RD works remotely and was available via e-mail and telephone.
Interview with the nursing home administrator (NHA) on March 12, 2025, at approximately 9:00 AM confirmed that the full-time RD's last day of employment was on March 7, 2025.
The NHA confirmed the current RD worked remotely on a part-time basis.
The NHA confirmed the facility failed to provide documented evidence the facility employed a full-time qualified food service director in the absence of a full-time qualified dietitian.
The NHA failed to provide documented evidence the services of the remote RD included face to face interactions with residents to ensure appropriate nutritional oversight for residents in the facility.
The NHA failed to provide documented evidence the current remote RD was scheduled to provide frequently scheduled consultations to the FSD.
28 Pa Code 201.18 (e)(1)(6) Management.
395456
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 395456 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Wyoming Valley 50 N.
Pennsylvania Ave.
Wilkes Barre, PA 18701
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.