Embassy Of Wyoming Valley

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.

395456 01/30/2026

Embassy of Wyoming Valley 50 N.

Pennsylvania Ave.

Wilkes Barre, PA 18701

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.

395456 01/30/2026

Embassy of Wyoming Valley 50 N.

Pennsylvania Ave.

Wilkes Barre, PA 18701

Review of the facility Safe Food Handling Practices Policy last reviewed January 23, 2026, revealed that hot food must be held at 135 degrees Fahrenheit or higher and cold foods must be held at 41 degrees or lower.

During an observation of the dietary department on January 26, 2026, at 10:00 AM, the facility's dishwasher was observed to be inoperable.

During an interview at that time, the Food Service Director (FSD) stated the dishwasher had been broken for approximately one month and confirmed that disposable paper products and plastic silverware were being used for resident meal service. A review of facility-provided information revealed the dishwasher malfunctioned and became inoperable on November 21, 2025. A review of Resident Food Committee Meeting Minutes dated December 25, 2025, revealed residents expressed concerns that the dishwasher had not yet been repaired and reported that food was being served cold. A subsequent review of Food Committee Meeting Minutes dated January 14, 2026, revealed residents continued to voice concerns that the dishwasher remained unrepaired and requested that hot foods be served on plates rather than Styrofoam.

During an interview on January 27, 2026, at 12:00 PM, Resident 12 stated that meals were frequently served cold and not palatable and reported meals being served on Styrofoam containers for several months due to the broken dishwasher.

During an interview on January 27, 2026, at 12:30 PM, Resident 26 stated dissatisfaction with the food and reported being tired of receiving cold meals.

During an interview on January 27, 2026, at 12:45 PM, Resident 30 stated the facility was aware he did not like the food and reported that meals were always cold.

During an interview on January 28, 2026, at 10:30 AM, Resident 1 stated they liked the food but reported it was frequently not hot enough. A test tray evaluation was conducted on the Third Floor Nursing Unit on January 28, 2026, during the lunch meal.

The test tray arrived on the unit at 12:16 PM and consisted of a hotdog on a bun, corn, pork and beans, ice cream, milk, and coffee.

The meal was served in Styrofoam containers, with coffee served in a thermal mug. At 12:28 PM, after the last resident on the unit was served, food temperatures were measured and recorded as follows:Hotdog on bun: 111 F (below the required minimum of 135 F)Corn: 106 F (below the required minimum of 135 F)Pork and beans: 122.6 F (below the required minimum of 135 F) The hot dog, corn, pork and beans tasted only lukewarm and were not palatable.

During an interview on January 28, 2026, at 1:15 PM, the Food Service Director confirmed that meals are required to be served at safe and appetizing temperatures and acknowledged that the test tray temperatures did not meet facility policy or regulatory requirements. A review of Test Tray Audits completed by the Registered Dietitian (RD) on November 21, 2025 (third floor lunch), November 28, 2025 (third floor lunch), December 4, 2025 (second floor lunch), December 12, 2025 (third floor lunch), January 9, 2026 (third floor lunch), and January 15, 2026 (second floor lunch) revealed that multiple hot food items were documented as not being served at palatable temperatures

During an interview on January 29, 2026, at 1:40 PM, the Registered Dietitian confirmed that complaints related to cold food had increased since the dishwasher became inoperable.

During an interview on January 29, 2026, at 2:30 PM, the Nursing Home Administrator confirmed the facility failed to ensure meals were consistently served at temperatures that were palatable and in accordance with regulatory requirements.

Refer F80228 Pa.

Code 201.14(a) Responsibility of licensee. 28 Pa.

Code 201.18 (e)(3) Management.

395456 01/30/2026

Embassy of Wyoming Valley 50 N.

Pennsylvania Ave.

Wilkes Barre, PA 18701

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.

395456 01/30/2026

Embassy of Wyoming Valley 50 N.

Pennsylvania Ave.

Wilkes Barre, PA 18701

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.

395456 01/30/2026

Embassy of Wyoming Valley 50 N.

Pennsylvania Ave.

Wilkes Barre, PA 18701

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.