Embassy Of Wyoming Valley

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

nor did it document that the risks associated with refusing transfer following a head injury were explained.

The progress note documented subsequent neurological checks were within normal limits. The resident was seated in a chair at the nurse's station for closer observation, and the note indicated the resident would continue to be monitored for the remainder of the shift. During a phone interview on January 30, 2026, at 11:42 AM, Resident Representative 1 explained that the facility contacted her on November 25, 2025, to inform her that Resident 98 had fallen and that an APN wrote an order to send the resident to the emergency department. Resident Representative 1 indicated she was informed that the facility did not think there was a need to send the resident to the emergency department. She further stated she was not informed that the resident struck her head, developed a fist-sized mass, was considered critical, or that the transfer was recommended to rule out a potentially life-threatening intracranial hemorrhage. During an

interview on January 30, 2026, at 12:05 PM, Employee 4, Licensed Practical Nurse, stated she contacted Resident Representative 1 on November 25, 2025, to report the fall and the APN's order for emergency department transfer. Employee 4 was unable to provide documented evidence that she communicated the critical assessment, head injury findings, size of the mass, or the specific risks associated with declining transfer, including the need for a CT scan to rule out intracranial bleeding. Review of the clinical record confirmed there was no documentation that this information was communicated. During an interview on January 30, 2026, at 12:30 PM, the Nursing Home Administrator (NHA) reviewed the above information and was unable to provide documentation demonstrating the facility ensured Resident Representative 1 received sufficient, detailed information to make an informed decision regarding treatment options following

the fall. Specifically, there was no documented evidence the facility communicated the APN's findings that

the resident's condition was critical, involved a significant head injury, and required emergency evaluation to rule out intracranial hemorrhage. During an interview on January 30, 2026, at 12:30 PM, the above information was reviewed with the Nursing Home Administrator (NHA). The NHA was unable to provide documented evidence the facility provided detailed information to Resident Representative 1 to make an informed decision about Resident 98's treatment options after the fall on November 25, 2025. Specifically, there was no documented evidence the facility communicated the APN's findings that the resident's condition was critical, involved a significant head injury, and required emergency evaluation to rule out intracranial hemorrhage. The facility failed to ensure the resident representative was fully informed of the risks, benefits, and treatment alternatives, as required, prior to declining the recommended transfer to the emergency department, thereby limiting the resident representative's ability to make an informed decision regarding Resident 98's care. Refer F-F842 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.2 (d)(7) Medical director. 28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Wyoming Valley

50 N. Pennsylvania Ave.

Wilkes Barre, PA 18701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations and resident and staff interviews, it was determined the facility failed to provide a clean, comfortable, and homelike environment for residents, including concerns expressed by six out of six residents during a resident group interview (Residents 46, 56, 71, 77, 83, and 94) and four out of 23 sampled residents (Residents 9, 14, 20, and 52).Findings include: An observation on January 27, 2026, at 12:07 PM in resident room [ROOM NUMBER] revealed dust, food pieces, debris, and dirt on the floor and under the window-side resident bed. An observation on January 27, 2026, at 12:09 PM in resident room [ROOM NUMBER] revealed water discoloration stains and pooling near the door side bed. Food pieces and dirt were observed under the door-side bed. The resident toilet was observed with brown stains and discolorations on the seat. The toilet dispenser roll was observed with a 2-inch gap between the metal dispenser and the wall, exposing the inside of the wall. [NAME] debris from the wall was observed on the floor underneath the toilet paper dispenser. An observation on January 27, 2026, at 12:20 PM, revealed the first floor main dining room felt cold. The wall thermostat in the main dining room was set to heat the room to 75 degrees Fahrenheit, but the wall thermometer was indicating the room temperature was 65 degrees Fahrenheit. An interview on January 27, 2026, at 12:20 PM with Residents 20 and Resident 52 who were present in the dining room for lunch stated that it is often cold in the main dining room. Resident 9 was observed to be wrapped in a blanket and stated that she needed to go back to her room right after she eats because it is too cold in the dining room. Resident 14, who was also in the main dining room for lunch, stated, Hey, turn on the heat. During an interview on January 27, 2026, at 12: 22 PM the director of maintenance confirmed that the heat was set at 75 degrees Fahrenheit but was not turning on and needed to be repaired. An observation on January 27, 2026, at 12:25 PM in resident room [ROOM NUMBER] revealed a blue fall mat with brown and gray liquid and discoloration stains. An observation on January 27, 2026, at 12:34 PM in resident room [ROOM NUMBER] revealed a broken toilet dispenser roll. The ceiling above the window-side bed was observed with a line of chipped paint extending for 3 feet. A follow-up

observation on January 28, 2026, at 8:55 AM revealed that the first-floor dining room felt cold. The wall thermostat in the main dining room was set to heat the room to 76 degrees Fahrenheit, but the wall thermometer was indicating the room temperature was 63 degrees Fahrenheit. During an additional

observation on January 28, 2026, at 9:15 AM, the nursing home administrator confirmed that the temperatures of four walls in the first-floor dining room were 64 degrees Fahrenheit, 62.6 degrees Fahrenheit, 61.2 degrees Fahrenheit, and 62.96 degrees Fahrenheit, respectively. During a resident group

interview on January 28, 2026, at 10:00 AM, six out of six residents (Residents 46, 56, 71, 77, 83, and 94) indicated they have a concern about the cold temperatures in the facility's dining room. An observation on January 28, 2026, at 12:22 PM in the third-floor Resident Pantry revealed a counter with pink liquid discoloration stains on the counter and dripping down the brown cabinets, dirt and debris pieces on the floor, a broken electrical outlet, and three ceiling blocks with 1 foot brown water discolorations, and a missing ceiling block. Additionally, the heating/cooling unit was observed with dozens of food pieces inside

the radiator fins. An observation on January 28, 2026, at 12:30 PM outside the third-floor Resident Dining room revealed white handrails with chipped and peeling paint. During an interview on January 30, 2026, at 12:30 PM, the above findings were reviewed with the nursing home administrator (NHA). The facility failed to provide a clean, comfortable, and homelike environment for residents. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Wyoming Valley

50 N. Pennsylvania Ave.

Wilkes Barre, PA 18701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

prepared and stated he had prepared the incorrect dessert. Interview with the Food Service Director on January 30, 2026, at 12:00 PM revealed that dietary staffing hours were reduced on December 30, 2025.

The FSD confirmed dietary aides for the supper meal were reduced from three aides and a cook to two aides and a cook, despite no significant decrease in resident census. The FSD stated that due to the reduction in staffing, he frequently assists with cooking and production duties. The FSD further acknowledged there were sanitation concerns within the kitchen and confirmed he was behind on ensuring completion of required food temperature logs and cleaning assignments necessary to maintain a sanitary food service environment. Interview with the Nursing Home Administrator (NHA) on January 30, 2026, at 1:00 PM confirmed that on December 30, 2025, the corporation reduced total daily dietary staffing hours, including cooks, dietary aides, and the Food Service Director, from approximately 48 to 51 total hours per day to approximately 40 hours per day. The NHA acknowledged that following the reduction, the Food Service Director was required to cook and assist with meal production more frequently due to decreased staffing levels. The facility failed to maintain sufficient dietary staffing to ensure meals were prepared and served in a sanitary manner, served at palatable temperatures, and served as planned according to the established menu. Refer F-F804, F-F812 28 Pa. Code 201.14(a)(b) Responsibility of licensee. 28 Pa. Code 201.18 (b)(1) Management.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Wyoming Valley

50 N. Pennsylvania Ave.

Wilkes Barre, PA 18701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Refer F80228 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18 (e)(3) Management.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Wyoming Valley

50 N. Pennsylvania Ave.

Wilkes Barre, PA 18701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0810

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, clinical record review, and staff interview, it was determined the facility failed to ensure the provision of adaptive dining equipment as prescribed to support safe eating for one of 23 sampled residents. (Resident 16)Findings include: A review of the clinical record revealed that Resident 16 was admitted to the facility on [DATE REDACTED], with diagnoses to include cerebral palsy (group of permanent movement, muscle tone, or posture disorders caused by abnormal brain development or damage before, during, or shortly after birth) and dysphagia (difficulty swallowing). Review of a quarterly Minimum Data Set Assessment (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated November 2, 2025, indicated that a BIMS interview (Brief Interview for Mental Status,

a tool to assess cognition) should not be completed with the resident due to the resident being rarely or never understood, had short term and long term memory problem, was severely cognitively impaired for decision making, and was dependent on staff for eating. A physician order dated April 4, 2024, noted an order for a coated spoon (protects teeth and prevents minor injuries to the gums and lips) with all meals.

Review of Resident 16's January Task Documentation Report between the dates of January 1, through January 28, 2026, revealed the coated spoon was not provided with meals for 31 out of 84 meals served.

Observation during the lunch meal on January 29, 2026, at 12:30 PM revealed a coated spoon was indicated on the resident's tray ticket. However, a plastic disposable spoon was provided on the resident's tray. Interview with Employee 9 Nurse Aide at this time confirmed the coated spoon was not provided.

Employee 9 confirmed the coated spoon was frequently not provided on the resident's tray. Employee 9 revealed the resident at times bites down on the spoon while feeding and having the coated spoon is beneficial to the resident. During an interview on January 29, 2026, at approximately 1:30 PM the Nursing Home Administrator acknowledged the facility failed to ensure the prescribed adaptive equipment (coated spoon) was consistently provided to the resident with meals and used in accordance with the physician's orders. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Wyoming Valley

50 N. Pennsylvania Ave.

Wilkes Barre, PA 18701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview conducted on January 28, 2026, the FSD confirmed food temperatures were required to be monitored and recorded at each meal. Review of the facility's Resident Refrigerators policy last reviewed January 23, 2026, revealed that it was the policy of the facility to ensure safe and sanitary use of any resident owned refrigerator. Leftover food will be dated upon receipt and discarded within three days.

Nursing and housekeeping were to discard any food that was out of compliance during the minimal weekly checks, which was to include assessing properly dated food items and discarding what was outdated, and monitor refrigerator temperatures.During an interview on January 27, 2026, at 11:00 AM, Employee 7 Licensed Practical Nurse stated Cooler Temperature Logs were posted on the outside of resident refrigerators and nursing or housekeeping staff were responsible for monitoring and documenting internal refrigerator temperatures daily. Observation of Resident 5's personal refrigerator located in the resident's room on January 27, 2026, at 11:00 AM, revealed a covered plastic container of food without a date indicating when it was placed in the refrigerator. Employee 7 was unable to identify how long the food had been stored or whether the three-day discard timeframe had been exceeded. Observation of the Cooler Temperature Log posted on the outside of Resident 5's refrigerator on January 27, 2026, at 11:00 AM, revealed the last documented internal refrigerator temperature was recorded on August 1, 2025. During an

interview on January 28, 2026, at 9:00 AM, the nursing home administrator was unable to provide additional information to demonstrate staff consistently monitored and documented resident refrigerator temperatures or ensured food was properly labeled and discarded to prevent foodborne illness.Refer F-F802 28 Pa Code 201.18 (e) (2.1) Management. 28 Pa Code 211.6(f) Dietary services. 28 Pa Code 211.10 (a)(d) Resident care policies. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Embassy of Wyoming Valley

50 N. Pennsylvania Ave.

Wilkes Barre, PA 18701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a

review of clinical records, facility-provided documentation, and employee interviews, it was determined the facility failed to ensure the accuracy and completeness of resident medical records for one of 3 closed records (Resident 98). Findings include:Review of the clinical record revealed that Resident 98 was admitted to the facility on [DATE REDACTED], and subsequently transferred to the emergency department on November 28, 2025. Following a fall on November 25, 2025, neurological check assessments (routine monitoring for signs and symptoms of head or brain injury) were initiated for Resident 98. Review of these neurological assessments revealed a total of 21 assessments were documented as completed. However, the electronic clinical record indicated the neurological assessment documentation was not finalized or locked until January 7, 2026. A lock date represents the point at which documentation is finalized and made read-only to prevent further alteration. Further review revealed that 13 of the 21 neurological assessments were not signed as completed until after Resident 98 had already been transferred to the emergency department on November 28, 2025. Additional record review revealed the presence of late-entry progress notes. A progress note dated November 27, 2025, at 11:29 AM documented that Resident 98 was awake, alert, oriented to self, and confused per baseline; however, the electronic record indicated this note was created

on November 30, 2025, at 2:31 PM. Similarly, a progress note dated November 28, 2025, at 10:37 AM documented that the resident was awake, alert, oriented to self, and confused per baseline, yet the electronic record showed this note was created on November 30, 2025, at 2:38 PM. In addition, the facility provided a certified registered nurse practitioner (CRNP) progress note dated November 26, 2025, and signed at 5:27 PM. This note was not uploaded into Resident 98's electronic clinical record. The facility also provided an amended version of the CRNP progress note dated November 26, 2025, and signed on November 28, 2025, at 6:33 PM; this amended note was likewise not uploaded into the resident's electronic clinical record. During an interview conducted on January 30, 2026, at 12:30 PM, the above findings were reviewed with the nursing home administrator (NHA). The NHA explained that facility staff were temporarily covering the duties and responsibilities of the medical records practitioner while the facility was in the process of arranging consultative medical records services. These findings demonstrated that the facility failed to ensure Resident 98's clinical record was accurate, complete, and reliably maintained. Refer F55228 Pa. Code 211.5 (f)(ii)(iii)(iv)(x)(i) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services.

Event ID:

Facility ID:

If continuation sheet