Gardens At Wyoming Valley, The

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 395456 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21738 potential for actual harm Based on a review of clinical records, select facility policy, observations, and staff interviews, it was Residents Affected - Some determined the facility failed to implement enhanced barrier infection control procedures for one out of 21 residents sampled (Resident 38), properly store clean towels designated for resident use in one out of two shower rooms on the Third Floor Nursing Unit, and maintain infection control practices related to reduce the potential for infections for one (Resident 36) out of two sampled residents with an indwelling urinary Foley catheter (flexible tube which is placed in the bladder to drain urine).

Findings include:

A review of facility policy titled Enhanced Barrier Precautions, last reviewed by the facility on February 19, 2025, revealed it is the facility policy to expand the use of personal protective equipment and refer to the use of gowns and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug-resistant organisms (MDROs) to staff hands and clothing. The policy indicates nursing home residents with wounds and indwelling medical devices are especially high risk for both the acquisition of and colonization with MDROs. The policy indicates any resident who requires enhanced barrier precautions will have clear signage posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves.

A clinical record review revealed Resident 38 was admitted to the facility on [DATE REDACTED], with diagnoses that included cerebral palsy (a condition that affects a person's ability to move and maintain balance and posture, caused by damage to the brain) and dysphagia (difficulty swallowing).

A physician's order, initially dated January 14, 2025, indicated that Resident 38 required enhanced barrier precautions (interventions implemented to prevent the transmission of novel or targeted multidrug-resistant organisms) due to the presence of a gastrostomy tube (surgically placed tube that provides direct access to

the stomach for feeding, hydration, or medication delivery).

Observations conducted on March 12, 2025, at 12:20 PM, and March 13, 2025, at 9:10 AM, revealed that no signage was posted outside Resident 38's room to indicate enhanced barrier precautions, nor were there any instructions regarding PPE requirements.

.

Interviews with Employee 4 Licensed Practical Nurse (LPN) and Employee 5 (Nurse Aide) on March 13, 2025, at 9:10 AM confirmed that no enhanced barrier precautions had been implemented for Resident 38, contrary to facility policy and infection control standards.

Observations conducted on March 11, 2025, at 7:30 PM, in the Third Floor Nursing Unit single shower room revealed that clean towels were placed inside the sink.

A subsequent observation on March 11, 2025, at 10:30 AM, in the presence of the Director of Nursing (DON), confirmed that a pile of clean towels was stored inside the sink.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 395456 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0880 An interview with the DON at this time confirmed that towels should not be stored in the sink, as this poses a risk of contamination. The DON acknowledged the facility is responsible for ensuring infection control Level of Harm - Minimal harm or procedures are fully implemented, including the proper storage of resident linens such as towels. potential for actual harm

A review of clinical records revealed Resident 36 was admitted to the facility on [DATE REDACTED], with diagnoses to Residents Affected - Some include neuromuscular dysfunction of the bladder (occurs when the nerves that control bladder function are damaged, leading to difficulty emptying or controlling the bladder), and benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty).

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 395456

F-F836

28 Pa. Code 211.9 (a)(l)(d)(k) Pharmacy Services.

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 395456 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 21738 Residents Affected - Few Based on review of select facility policy, observation, and staff interview it was determined the facility failed to ensure that drugs were stored at an acceptable temperature on two of two nursing 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 395456 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0761 28 Pa Code 211.12(d)(1) Nursing services.

Level of Harm - Minimal harm or 28 Pa Code 211.9(a)(1)(k) Pharmacy services potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 395456 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Level of Harm - Minimal harm or potential for actual harm 21738

Residents Affected - Many Based on staff interview and a review of employee qualifications it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian.

Findings include:

The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 395456 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0836 Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted Level of Harm - Minimal harm or professional standards. potential for actual harm 21738 Residents Affected - Few Based on a review of the facility's automated emergency medication system, applicable state regulations, facility policies, and staff interviews, it was determined that the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring pharmacy services necessary for daily pharmacy operations according to state requirements of Pa. Code title 49.

Findings include:

A review of Pennsylvania Code title 49, part I, subpart A, chapter 27 - STATE BOARD OF PHARMACY, 49 Pa. Code S 27.204 - Automated medication systems revealed the following:

(a) This section establishes standards applicable to licensed pharmacies that utilize automated medication systems which may be used to store, package, dispense or distribute prescriptions.

(b) A pharmacy may use an automated medication system to fill prescriptions or medication orders provided that:

(1) The pharmacist manager, or the pharmacist under contract with a long-term care facility responsible for

the dispensing of medications if an automated medication system is utilized at a location which does not have a pharmacy onsite, is responsible for the supervision of the operation of the system.

(4) The automated medication system must electronically record the activity of each pharmacist, technician or other authorized personnel with the time, date and initials or other identifier so that a clear, readily retrievable audit trail is established. A pharmacist will be held responsible for transactions performed by that pharmacist or under the supervision of that pharmacist.

(c) The pharmacist manager or the pharmacist under contract with a long-term care facility responsible for

the delivery of medications shall be responsible for the following:

(1) Reviewing and approving all policies and procedures for system operation,safety, security, accuracy, access and patient confidentiality.

(2) Ensuring that medications in the automated medication system are inspected, at least monthly, for expiration date, misbranding and physical integrity, and ensuring that the automated medication system is inspected, at least monthly, for security and accountability.

(3)Assigning, discontinuing or changing personnel access to the automatedmedication system.

(4) Ensuring that the automated medication system is stocked accurately, and an accountability record is maintained in accordance with the written policies and procedures of operation.

(5) Ensuring compliance with the applicable provisions of State and Federal law.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 395456 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

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 0836 (6) Set forth methods that ensure that access to the automated medication system for stocking and removal of medications is limited to licensed pharmacists or the pharmacist's designee acting under the supervision Level of Harm - Minimal harm or of a licensed pharmacist. An accountability record which documents all transactions relative to stocking and potential for actual harm removing medications from the automated medication system must be maintained.

Residents Affected - Few (g) The pharmacist manager shall be responsible for ensuring that, prior to performing any services in connection with an automated medication system, all licensed practitioners and supportive personnel are trained in the

pharmacy's standard operating procedures with regard to automated medication systems set forth in the written policies and procedures. The training shall be documented and available for inspection.

A review of the facility policy Medication Ordering and Receipt Policy reviewed February 19, 2025, revealed that a designated staff member will be responsible for immediately adding the medications to the Automated Medication System and updating the quantities in the system.

An interview with Employee 2 (registered nurse) on March 13, 2025 at 10:10 A.M. revealed she was the designated staff member responsible for receiving the medications from the pharmacy courier and filling the Automated Medication System.

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.

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