Pennsylvania Department of Health
EMBASSY OF SCRANTON
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF SCRANTON
Inspection Results For:

There are 181 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


EMBASSY OF SCRANTON - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey and revisit survey completed on July 15, 2026, it was determined the Embassy of Scranton failed to correct the federal deficiencies cited during the survey of May 8, 2026, and continued to be out of compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.\~

Plan of Correction:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Plan of Correction - To be completed: 08/07/2026

F801- Qualified Dietary Staff

1. Corrective action for affected resident (s): Immediately upon identification of the deficiency, the facility secured services of a qualified Registered Dietitian part time to provide clinical nutrition oversight and a full-time Certified Dietary Manager.

2. How other residents were identified: A house wide audit was completed, and any nutritional issues will be followed up by the RD.

3. Systemic changes: The Administrator, Dietary Manager, and Director of Nursing were educated regarding CMS F801 requirements, including the requirement for qualified dietary leadership and routine Registered Dietitian oversight. Administration/ IDT will review in morning clinical meetings and follow up with the RD.

4. Monitoring/QAPI: NHA/Designee will audit qualified dietary leadership and staffing in the kitchen. RD will complete a visit report onsite weekly x4 weeks then monthly x2 months; QAPI review.

Completion Date: 8/7

483.10(g)(6)-(9) REQUIREMENT Right to Forms of Communication w/ Privacy:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(g)(6) The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. This includes the right to retain and use a cellular phone at the resident's own expense.

§483.10(g)(7) The facility must protect and facilitate that resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to:
(i) A telephone, including TTY and TDD services;
(ii) The internet, to the extent available to the facility; and
(iii) Stationery, postage, writing implements and the ability to send mail.

§483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to:
(i) Privacy of such communications consistent with this section; and
(ii) Access to stationery, postage, and writing implements at the resident's own expense.

§483.10(g)(9) The resident has the right to have reasonable access to and privacy in their use of electronic communications such as email and video communications and for internet research.
(i) If the access is available to the facility
(ii) At the resident's expense, if any additional expense is incurred by the facility to provide such access to the resident.
(iii) Such use must comply with State and Federal law.

Observations:

Based on observations and staff interviews, it was determined the facility failed to ensure residents had reasonable access to functional telephones that afforded privacy during telephone communications on two of two nursing units.

Findings include:

During an environmental tour of the second-floor nursing unit on July 14, 2026, at 10:11 AM, no functional portable telephone was available for resident use in a private location. A portable black telephone was observed on a desk behind an enclosed office at the nurses' station. An attempt to operate the telephone revealed there was no dial tone.

An interview conducted at that time with Employee 1, a Registered Nurse (RN), revealed the portable telephone had not functioned for an extended period. Employee 1 reported that when residents requested telephone access, staff offered the Nursing Supervisor's cellular telephone. No alternative resident-accessible telephone was available in a location that afforded privacy from being overheard during telephone conversations.

An interview with Employee 2, a Licensed Practical Nurse (LPN), on the third-floor nursing unit on July 14, 2026, at 10:45 AM revealed there had not been a functioning cordless telephone available for resident use on the unit for more than one year. Employee 2 reported residents either used the land line telephone located at the nurses' station, where conversations could be overheard by individuals in the surrounding area, or were offered the Nursing Supervisor's cellular telephone. No resident-accessible telephone was available in a private location that permitted confidential telephone communications.

The observations and staff interviews demonstrated that the facility failed to provide residents on either nursing unit with reasonable access to a functional telephone located in an area that afforded privacy for telephone communications.

During an interview on July 15, 2026, at 3:15 PM, the Nursing Home Administrator confirmed the facility did not provide residents on all nursing units with access to a functional resident telephone that afforded privacy during telephone communications.

28 Pa. Code 201.18(b)(2)(e)(1) Management.

28 Pa. Code 201.29(a) Resident rights.

Plan of Correction - To be completed: 08/07/2026

1. Corrective action for affected resident (s): Residents immediately provided access to functioning resident telephones in private locations; defective phones repaired/replaced.

2. How other residents were identified: Audit completed on all units by the maintenance director, or designee, verifying functional private resident telephones.

3. Systemic changes: Administrator educated nursing, maintenance and supervisors regarding resident rights and weekly testing process. Residents will be educated upon admissions and reminded during resident council meetings that private telephones are readily available upon request. Signage will be posted at each nurse's station and other designated locations informing residents of the availability of private phone access and how to request assistance.

4. Monitoring/QAPI: Maintenance/designee will audit telephones for functionality that they are access and document any deficiencies and replace or fix as needed daily x2 weeks then weekly x2 weeks; QAPI review monthly.

Completion Date: 8/7

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on a review of clinical records, facility policy, resident observations, and resident and staff interviews, it was determined the facility failed to implement infection prevention and control measures consistent with nationally recognized standards of practice for the evaluation and management of suspected scabies for two of 15 residents reviewed (Resident 1 and Resident 2).

Findings include:

According to the Centers for Disease Control and Prevention (CDC) guidance titled "Public Health Strategies for Scabies Outbreaks in Institutional Settings" (updated December 18, 2025), residents with confirmed or suspected scabies (a skin condition caused by microscopic mites that burrow into the skin and lay eggs, resulting in intense itching, often worse at night, and a pimple-like rash) should be placed on contact precautions (infection prevention measures that require the use of gowns and gloves during resident care and avoidance of direct skin-to-skin contact). The guidance stated that roommates or close contacts with prolonged skin exposure should be identified, offered prophylactic treatment, and monitored but do not require room isolation.

A review of the facility policy titled, "Head Lice and Scabies Exposure and Treatment Policy", last reviewed March 26, 2026, indicated residents who contract scabies or head lice are treated according to current standards of practice to eradicate the infestation and prevent further exposure and transmission. According to the policy, proper treatment and infection control measures should be utilized to prevent outbreaks within the facility. Upon signs and symptoms of scabies, the provider will be notified, treatment will be administered according to manufacturer's instructions, the infested resident will be placed in a single occupancy room, and appropriate transmission-based precautions (extra precautions applied when a resident is known or suspected to be infected with disease causing organism that spread via contact, droplets, or airborne route) will be initiated according to the policy.

A clinical record review revealed Resident 2 was admitted to the facility on July 9, 2026, with a diagnosis of systolic heart failure (a condition in which the left side of the heart does not pump blood effectively).

Resident 2's Brief Interview for Mental Status (BIMS) (a standardized assessment used to evaluate attention, orientation, and short-term memory) dated July 14, 2026, identified a score of 10, indicating moderate cognitive impairment. A score of 8-12 means noticeable difficulties with short-term memory or orientation, such as recalling words or identifying the current date correctly.

Observation of Resident 2 on July 15, 2026, at 11:35 AM revealed multiple bright red circular areas on the resident's upper and lower extremities. During interview, Resident 2 reported skin discomfort while gesturing toward the affected areas.

A review of Resident 2's clinical record review revealed the admission assessment dated July 9, 2026, documented multiple scratches involving the arms, legs, forehead, and chest. A nursing progress note completed the same evening documented similar findings.

A nursing progress note dated July 10, 2026, documented notification of the nurse practitioner, who ordered treatment for possible scabies with Permethrin 5% topical cream (a medication used to kill the mites and eggs that cause scabies).

Physician orders dated July 11, 2026, directed staff to apply Permethrin 5% cream from the neck down at bedtime, leave the medication on for eight to fourteen hours, then wash it off the following morning and provide clean clothing.

The electronic Medication Administration Record (eMAR) documented administration of Permethrin on July 11, July 12, July 13, and July 14, 2026.

Despite ongoing treatment for suspected scabies, the clinical record lacked evidence Resident 2 was placed on contact precautions or that additional infection prevention measures were implemented consistent with CDC guidance or the facility's infection prevention policy.

According to the clinical record, Resident 2 underwent evaluation by the wound care nurse practitioner on July 15, 2026, at 6:45 AM. Although the documentation described a Stage IV pressure injury of the sacrum (a very deep wound over the lower back near the tailbone), it did not include any information related to the red, circular areas on Resident 2's extremities.

An attempt to contact the wound care nurse practitioner who evaluated and treated Resident 2, on July 17, 2026, at 9:00 AM was unsuccessful, and no return call was received.

According to the CDC, "Public Health Strategies for Scabies Outbreaks in Institutional Settings" (2025, December 18) residents who share a room with an individual diagnosed with scabies do not require room isolation. Residents who share a room with an individual diagnosed with scabies must be promptly identified as close contacts, receive prophylactic treatment as indicated, and be monitored, while contact precautions are implemented for the affected resident.

A review of the clinical record revealed Resident 1 was admitted to the facility on May 14, 2026, with diagnoses to include acute embolism and thrombosis of unspecified deep veins of lower bilateral lower extremities (both legs suddenly developed blood clots in deep veins, and pieces of clots may have already broken off and travel elsewhere in the body).

A review of Resident 1's admission Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 21, 2026, revealed that Resident 1 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13 through 15 indicates normal thinking and memory; little to no cognitive impairment).

Resident 1 resides in the same room as Resident 2. On July 13, 2026, the spouse of Resident 1 communicated concerns stating Resident 1 informed him she was in "quarantine" due to the roommate (Resident 2) having an "infectious disease". The spouse of Resident 1 expressed concern regarding its impact on discharge and physical therapy attendance due to the "quarantine".

Clinical record review for Resident 1 lacked evidence the facility identified the resident as a close contact following initiation of treatment for suspected scabies in the roommate. The record contained no evidence of provider notification, comprehensive skin assessment, monitoring for signs or symptoms of scabies, consideration of prophylactic treatment, or implementation of additional infection prevention measures.

Observation confirmed Resident 1 remained in the shared room on July 14, 2026, at 10:11 AM and was observed in a common lounge area on July 15, 2026, at 11:30 AM.

The findings were reviewed with the Director of Nursing on July 15, 2026, at 2:35 PM. During the interview, the DON stated there was uncertainty regarding the cause of Resident 2's skin condition and indicated that scabies had initially been considered among the possible causes. The DON stated Resident 2 had not been placed on transmission-based precautions while the skin condition was being evaluated.

During a subsequent interview on July 15, 2026, at 3:15 PM, the Director of Nursing and the Nursing Home Administrator stated the cause of Resident 2's skin condition had not been definitively identified. The clinical record lacked documentation that Resident 2 was evaluated by a skin specialist or that infection prevention measures consistent with the facility's policy and current Centers for Disease Control and Prevention (CDC) guidance were implemented while scabies remained a suspected diagnosis.

28 Pa Code 211.10(c)(d) Resident care policies.

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

Plan of Correction - To be completed: 08/07/2026

1. Corrective action for affected resident (s): Skin Assessment on resident 2 was performed by nursing, provider was notified and dermatology was consulted as per request.

2. How other residents identified: ADON/ Designee will do skin assessments on the past 30 days of admitted residents.

3. Systemic changes: DON/Designee will educate all staff on the identification and spread transmission-based precautions. For all identified transmission-based concerns, just in time staff education will be provided and corrective actions put in place.

4. Monitoring/QAPI: DON/designee will audit 5 days x2 weeks then weekly x2 weeks; QAPI review monthly. new admissions weekly and 2 LTC residents x4 weeks then monthly x2 months; QAPI review.

Completion Date: 8/7

483.75(c)(1)-(4)d)(1)(2)(e)(1)-(3)(g)(2)(ii)(iii) REQUIREMENT QAPI/QAA Improvement Activities:

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on a review of the Statement of Deficiencies from the survey ending May 8, 2026, the facility's Plan of Correction, revisit survey findings, and staff interview, it was determined the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain an effective, ongoing program that monitored and sustained corrective actions to prevent the recurrence of previously cited deficient practices related to infection prevention and control, food procurement, sanitary food storage, preparation and service, and qualified dietary oversight.

Findings include:

During the survey ending May 8, 2026, the facility was cited for failing to implement measures to prevent the potential spread of infection.

In response, the facility submitted a Plan of Correction indicating personal protective equipment (PPE), such as gloves, gowns, and other protective items used to reduce the spread of infection, would be provided to residents who required it. The facility further indicated that each resident would be evaluated to determine the need for PPE, nursing staff, nursing assistants, and department managers would receive education regarding identifying residents requiring PPE, department managers would audit the availability of PPE during routine rounds, and the Administrator would review the daily audit results. The Plan of Correction indicated the audit findings would be reviewed during the monthly Quality Improvement meeting, the QAPI Committee would determine whether additional auditing was necessary after three consecutive months of compliance, and monitoring would continue based on the Committee's recommendations. The facility identified July 10, 2026, as the completion date for these corrective actions.

However, during the revisit survey ending July 15, 2026, the facility again failed to ensure infection prevention and control measures were consistently implemented under the same regulatory requirement.

During the survey ending May 8, 2026, the facility was also cited for failing to ensure sanitary conditions and safe food handling practices in the kitchen.

In response, the facility submitted a Plan of Correction indicating the Dietary Director or designee would re-educate dietary staff regarding the facility's sanitation policy and complete kitchen sanitation audits twice weekly to ensure sanitary conditions and resident safety were maintained. The facility further indicated the audit findings would be reviewed during the monthly Quality Improvement meeting, the QAPI Committee would determine whether continued auditing was necessary after three consecutive months of compliance, and monitoring would continue based on the Committee's recommendations. The facility identified July 10, 2026, as the completion date for these corrective actions.

However, during the revisit survey ending July 15, 2026, the facility again failed to maintain sanitary conditions and safe food handling practices in the kitchen under the same regulatory requirement.

During the survey ending May 8, 2026, the facility was also cited for failing to ensure sufficient qualified dietary oversight.

In response, the facility submitted a Plan of Correction indicating the facility had retained an additional Registered Dietitian (RD), a qualified nutrition professional responsible for assessing residents' nutritional needs and overseeing food and nutrition services. The Plan of Correction indicated one Registered Dietitian would conduct weekly on-site visits while another Registered Dietitian would continue to provide remote nutritional oversight. The facility indicated the Corporate Director of Dietary would review the Registered Dietitians' responsibilities to ensure regulatory compliance, the Administrator or designee would audit the Registered Dietitians' weekly hours and on-site visits, and resident care plans identified during the survey would be reviewed and revised, as appropriate. The facility identified July 10, 2026, as the completion date for these corrective actions.

However, during the revisit survey ending July 15, 2026, the facility again failed to ensure sufficient qualified dietary oversight under the same regulatory requirement.

An interview with the Nursing Home Administrator during the revisit survey acknowledged the previously implemented corrective actions had not been sustained.

The recurrence of the same deficient practices following implementation of the facility's Plans of Correction demonstrated that the QAPI Committee failed to effectively monitor, evaluate, and sustain corrective actions. As a result, the Committee did not identify that the corrective measures were ineffective or ensure additional performance improvement activities were implemented to prevent the recurrence of the previously cited deficiencies.

Cross Ref. F880, F812, F801

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

28 Pa. Code 201.18 (b)(1) Management.

Plan of Correction - To be completed: 08/07/2026

1. Corrective action for affected resident (s): Immediate corrective actions were initiated. The QAPI committee convened to conduct a comprehensive review of all previously cited deficiencies related to IP, Food Procurement and handling as well as Qualified Dietary Oversight.

2. How other residents were identified: QAPI oversight affects all departments and all residents, every resident had the potential to be affected.

3. Systemic changes: The Administrator and DON were educated on the QAPI Program by RDO to ensure compliance to then be able to strengthen oversight and accountability.

4. Monitoring/QAPI: Designee will audit that the facility's QAPI program is actively identifying, tracking, and addressing performance improvement opportunities, including follow-up on survey deficiencies. weekly x2 weeks then monthly x2 months; QAPI review monthly including regional support via teams meeting x3 months.

Completion Date: 8/7

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

A review of a facility policy entitled "Dating for Food Storage" last reviewed by the facility on March 26, 2026, indicated bulk items were to be stored in approved containers with tight fitting lids with a label on the lid and side container with the products name and date the container was filled. The policy stated that all food items requiring time and temperature control should be labeled with the date opened and a use by date indicate when the product is to be discarded. The policy detailed that opened products can be kept for a 7-day period after opening and then discarded.

A review of a facility policy titled "Sanitary Conditions", last reviewed by the facility on March 26, 2026, revealed all food items requiring refrigeration will be stored above the floor on shelves. The policy revealed all opened food items will be stored in proper containers and labeled and dated.

During the initial tour of the dietary department on July 15, 2026, at 10:30 AM, accompanied by the facility's Corporate Dietary Manager, the following observations were made:

Upon entering the dietary department, a large amount of dirty water leaked from the dishwashing system onto the kitchen floor in the food preparation area. An outdoor brick supported the leaking pipe. The water had accumulated on the floor and slowly drained toward a floor drain. The Corporate Dietary Manager stated the dishwasher had been leaking for some time and maintenance was aware of the problem.

Upon entering the dietary department, a large amount of dirty water leaked from the dishwashing system onto the kitchen floor in the food preparation area. An outdoor brick supported the leaking pipe. The water had accumulated on the floor and slowly drained toward a floor drain. The Corporate Dietary Manager stated the dishwasher had been leaking for some time and maintenance was aware of the problem.

The walk-in cooler contained a pizza box with a partially eaten pizza stored on top of pre-made desserts scheduled to be served to residents for lunch that day. The Corporate Dietary Manager stated the pizza belonged to staff working the previous evening and acknowledged staff were not permitted to store personal food in resident food storage areas.

The walk-in cooler also contained an opened bottle of thickened milk (milk that has been modified to a thicker consistency for individuals who require thickened liquids to swallow safely). The bottle was marked as opened on June 17, 2026, and remained in the cooler on the date of observation, July 15, 2026.

The walk-in cooler contained a package of hot dogs wrapped in aluminum foil. Although a date had been written on the foil, it had become partially erased and was no longer legible, preventing staff from determining when the product had been stored.

The produce refrigerator contained an open, partially consumed bottle of Gatorade stored next to fresh produce. The refrigerator also contained a grocery bag holding yogurt and a spoon. The Corporate Dietary Manager stated the items belonged to staff and should not have been stored in the produce refrigerator.

During an interview on July 15, 2026, at 2:00 PM, the Nursing Home Administrator reviewed the above findings and acknowledged the facility had not maintained the dietary food storage areas in a sanitary manner consistent with facility policy.

28 Pa. Code 201.18 (e) (2.1) Management.

Plan of Correction - To be completed: 08/07/2026

1. Corrective action for affected resident (s): Immediate corrective actions were implemented. The standing water was immediately cleaned and disinfected. The maintenance director ordered a specialized valve for the dishwasher. The brick was removed and all items were fixed. Kitchen was audited to identify any concerns.

2. How other residents were identified: No residents were identified as experiencing illness or adverse outcomes related to these findings.

3. Systemic changes: Dietary Manager, Maintenance Director, Housekeeping Director, Administrator and DON will be educated on the sanitation policy by the Regional Dietary Manager regarding the storage of food and post approved staff food storage locations.

4. Monitoring/QAPI: Designee will audit Inspect the kitchen, dish room, food storage areas, equipment, and dining service areas to verify compliance with food safety and sanitation standards. daily x2 weeks then weekly x2 weeks; QAPI review monthly.

Completion Date: 8/7

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and staff interviews, it was determined the facility failed to maintain a clean, sanitary, functional, and comfortable environment on two of three resident care units observed (second and third floor resident units).

Findings include:

On July 15, 2026, at 12:00 PM, observations of the second floor resident hallway revealed a strong, pervasive malodor present throughout the hallway.

On July 15, 2026, at 12:10 PM, observations of the third floor resident hallway revealed sticky flooring with visible accumulations of dark-colored dirt and debris along the corners of the hallways.

On July 15, 2026, at 12:15 PM, observations of the second floor dining room revealed multiple residents seated for dining while garbage remained beneath several dining tables, including a crushed empty nutritional supplement container, straw wrappers, a used plastic fork, and scattered popcorn on the floor.

On July 15, 2026, at approximately 12:20 PM, observations of the hallway outside Room 219 revealed a pair of used disposable gloves on the floor and multiple dark-colored splatters of an unidentified substance on the hallway floor. The floor surface was sticky and produced an audible sticking sound as individuals walked across it.

During an interview on July 15, 2026, at 3:00 PM, the Nursing Home Administrator and Director of Nursing accompanied the surveyor during a review of the above observations and acknowledged the conditions observed.

28 Pa Code 201.18(1)(3) Management.

Plan of Correction - To be completed: 08/07/2026

F584 – Safe/Clean/Comfortable Environment

1. Corrective action for affected resident (s): Environmental services immediately cleaned cited areas, removed debris, addressed odors, ordered new floor cleaning equipment and have reached out to a company to deep clean floors and resident's areas.

2. How other residents were identified: Facility-wide environmental rounds completed by the housekeeping department with the new implemented cleaning schedule and assignments with extra oversight from ambassadors on all resident care areas.

3. Systemic changes: Housekeeping staff re-educated on cleaning standards, odor management and dining room turnover; supervisors/ department heads educated on environmental rounds.

4. Monitoring/QAPI: Housekeeping Director/designee will audit resident care areas, common areas, dining rooms, bathrooms, corridors, and other facility spaces for cleanliness, odors, debris, and compliance with housekeeping standards to perform 5 days per week x2 weeks then weekly x2 weeks; QAPI review.

Completion Date: 8/7

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on a review of facility clinical records, select facility policy, and staff interviews, it was determined the facility failed to develop and update a resident-specific baseline care plan to include interim, person-centered interventions necessary to address newly identified care needs for one of 15 sampled residents reviewed (Resident 2).

Findings include:

According to the Centers for Disease Control and Prevention (CDC) guidance titled "Public Health Strategies for Scabies Outbreaks in Institutional Settings," updated December 18, 2025, residents with confirmed or suspected scabies (a contagious skin infestation caused by microscopic mites that burrow beneath the skin, causing intense itching and a rash) should be placed on contact precautions, including the use of gowns and gloves and avoidance of direct skin-to-skin contact. The guidance further states that close contacts should be identified, monitored, and offered prophylactic treatment, as appropriate.

A review of the facility's Baseline Care Plan Policy, reviewed March 26, 2026, revealed the facility would develop and implement a baseline care plan within 48 hours of admission. The policy indicated the baseline care plan must include the minimum healthcare information necessary to provide effective, person-centered care until the comprehensive care plan is developed such as initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations if applicable. The policy required the baseline care plan to include interventions addressing the resident's current needs and health and safety concerns, including interventions necessary to prevent injury or decline and address identified supervision needs.

A review of the clinical record revealed Resident 2 was admitted to the facility on July 9, 2026, with diagnoses including acute-on-chronic systolic congestive heart failure (a sudden worsening of symptoms in a person with chronic heart failure in which the heart cannot pump blood effectively).

A nursing progress note dated July 9, 2026, at 10:59 PM documented the resident's skin was intact with scratches noted on the arms, legs, and forehead.

A nursing progress note dated July 10, 2026, at 4:02 PM documented the Registered Nurse Supervisor contacted the Certified Registered Nurse Practitioner (CRNP) regarding suspected scabies exposure. The CRNP ordered Permethrin 5% topical cream (a prescription medication applied to the skin to treat scabies) as prophylactic treatment, meaning treatment intended to prevent the development or spread of disease following suspected exposure.

A physician's order dated July 10, 2026, directed staff to apply Permethrin 5% cream from the neck down at bedtime for 10 days as prophylactic treatment for suspected scabies exposure.

A review of the baseline care plan, initiated July 9, 2026, revealed the resident's identified needs included Enhanced Barrier Precautions (infection prevention measures used during high-contact care activities for residents with certain medical devices or wounds). However, after the resident's newly identified need for prophylactic treatment related to suspected scabies exposure, the facility failed to update the baseline care plan to identify the resident's contact precaution status or include individualized interim interventions instructing staff on the infection prevention measures necessary while the resident received treatment.

During an interview on July 16, 2026, at 3:00 PM, the Director of Nursing confirmed Resident 2 received prophylactic treatment related to suspected scabies exposure and acknowledged the baseline care plan did not include individualized interventions addressing the resident's contact precautions. The Director of Nursing further confirmed the baseline care plan was not consistent with the facility's Baseline Care Plan Policy.

28 Pa. Code 211.10 (c)(d) Resident care policies.

28 Pa Code 211.12 (d)(3)(5) Nursing services.

28 Pa. Code 211.5(f)(iii) Medical records.

Plan of Correction - To be completed: 08/07/2026

F655 – Baseline Care Plans

1. Corrective action for affected resident (s): Resident-specific, resident 2 baseline care plan updated to reflect current needs and interventions.

2. How other residents were identified: Audit of all new admissions within previous 30 days completed by the Director of Nursing or designee for baseline care plan compliance.

3. Systemic changes: Nursing staff and IDT educated by the Director of Nursing or designee regarding 48-hour baseline care plan requirements and updating significant changes.

4. Monitoring/QAPI: DON/designee will audit 5 days x2 weeks then weekly x2 weeks; QAPI review monthly. new admissions weekly and 2 LTC residents x4 weeks then monthly x2 months; QAPI review.

Completion Date: 8/7

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on a review of clinical records, facility policy, manufacturer's prescribing information, and staff interviews, it was determined the facility failed to ensure medications were free from unnecessary use by administering permethrin cream without adequate clinical indication and for an excessive duration for one of 15 sampled residents (Resident 2).

Findings include:

Review of the facility policy titled "Medication Administration" last reviewed March 26, 2026, indicates medications are administered as ordered by the physician and in accordance with professional standards of practice. The policy indicated the facility will administer medications by utilizing best practice guidelines (strategies, methods, or techniques that have been proven through research and evaluation to be effective and efficient in achieving desired results).

A clinical record review revealed Resident 2 was admitted to the facility on July 9, 2026, with a diagnosis of systolic heart failure (a condition in which the left side of the heart cannot pump blood effectively throughout the body). A review of Resident 2's Brief Interview for Mental Status (BIMS) assessment, dated July 14, 2026, revealed Resident 2 had a BIMS score of 10, indicating moderate cognitive impairment. The BIMS is a standardized assessment used to evaluate a resident's attention, orientation, and ability to register and recall new information. A score of 8 through 12 indicates moderate cognitive impairment.

A clinical record review of the document titled "Admission Evaluation with Baseline Care Plan v.6" revealed Resident 2 was observed to have "multiple scratches and bruising" upon admission on July 9, 2026.

A Clinical record review revealed an admission skin integrity evaluation on July 9, 2026, documented observed scratches and blisters on bilateral lower extremities. The assessment documented a scratch located on the forehead and upper chest. The assessment documented multiple scratches and bruising of unspecified areas. The goal portion of the assessment documented a goal for the resident to experience healing of the current skin impairment and prevent future skin breakdown.

A nursing progress note dated July 10, 2026, at 4:02 PM documented the nurse contacted the nurse practitioner, who ordered permethrin 5% topical lotion (a prescription-strength medication used to treat scabies. It works by paralyzing and killing the mites and their eggs), to prophylactically (to provide medication as a preventative) treat possible scabies (a skin condition caused by tiny mites that burrow into the skin, causing intense itching, and a rash that looks like small pimples or scaly lines).

A physician's order dated July 10, 2026, directed staff to apply permethrin 5% cream from the resident's neck down at bedtime for scabies for a duration of 10 days, leave the medication on for 8 to 14 hours, wash it off the following morning, and provide clean clothing after bathing. A subsequent physician order dated July 11, 2026, again directed staff to administer permethrin for 10 days.

Review of the clinical record failed to identify documentation of a provider assessment confirming a diagnosis of scabies. The record also lacked documentation of diagnostic evaluation, including dermoscopy (the use of a magnifying device to examine skin lesions) or skin scraping (collecting a small sample of skin to examine under a microscope for scabies mites or eggs), to support treatment with permethrin.

Review of the July 2026 Medication Administration Record revealed staff administered permethrin cream on the evenings of July 11, July 12, July 13, and July 14, 2026.

According to the manufacturer's prescribing information for permethrin 5% cream, last updated March 9, 2026, a single application is generally sufficient to treat scabies. The prescribing information directs the cream to be applied once, left on the skin for 8 to 14 hours, and then removed by bathing or showering and changing into clean clothing. Approximately 30 grams is usually sufficient for an average adult.

The manufacturer's prescribing information states that mild burning, stinging, or itching may occur after application. The prescribing information further explains that persistent pruritus (itching) after treatment may continue even when treatment has been successful and does not indicate treatment failure or the need for additional applications. Retreatment should only be considered 7 to 14 days after the initial application if live mites are demonstrated to remain. Documented adverse reactions include burning, stinging, itching, redness, rash, and skin inflammation. The prescribing information warns that repeated or excessive use may increase the risk of skin irritation and other adverse skin reactions.

Observation of Resident 2 on July 15, 2026, at 11:35 AM revealed widespread bright red circular areas involving the upper and lower extremities and sacral area (the lower back and upper buttocks). The affected areas appeared crusted and scabbed, demonstrated extensive scratching, and contained dried blood.

During an interview on July 15, 2026, at 11:15 AM, the facility's Infection Preventionist stated they believed Resident 2 had already been cleared of scabies. The Infection Preventionist acknowledged the resident was never placed on transmission-based precautions because both the Infection Preventionist and Director of Nursing believed the resident did not have scabies.

During an interview on July 15, 2026, at 2:10 PM, the Director of Nursing stated the physician order should not have directed permethrin treatment for 10 days and acknowledged the order had been entered incorrectly. The Director of Nursing confirmed nursing staff continued administering the medication without recognizing the error and further stated Resident 2 did not have scabies and the medication should have been discontinued.

The facility administered permethrin cream without documented clinical evidence supporting its use and continued treatment beyond accepted prescribing recommendations. As a result, Resident 2 received unnecessary medication without an adequate clinical indication and for an excessive duration, exposing the resident to avoidable adverse medication effects, including worsening skin irritation.

These findings were reviewed with the Director of Nursing and the Nursing Home Administrator on July 15, 2026, at 3:30 PM.

28 Pa. Code 211.10 (c)(d) Resident care policies.

28 Pa. Code 211.12 (d)(1)(5) Nursing services.

28 Pa. Code 211.9 (a)(1)(d) Pharmacy services.

Plan of Correction - To be completed: 08/07/2026

1. Corrective action for affected resident (s): Resident #2's physician orders, medication regimen, and clinical record were immediately reviewed by the attending provider, Director of Nursing, Infection Preventionist, and Consultant Pharmacist. Resident's medication was discontinued.

2. How other residents were identified: All current residents receiving topical anti-parasitic medications, antimicrobial medications within the previous thirty (30) days were reviewed by the Director of Nursing, Infection Preventionist to ensure medication duration was appropriate, stop dates were appropriate and MARs accurately reflected physician orders.

3. Systemic changes: Licensed staff were educated by the Director of Nursing, or designee, regarding unnecessary medication requirements for verification of medication indications prior to administration.

4. Monitoring/QAPI: DON/designee will audit resident medication regimens to ensure medications have appropriate indications, physician orders, stop dates when applicable, and accurate MAR documentation daily x2 weeks then weekly x2 weeks; QAPI review monthly.

Completion Date: 8/7

§ 201.14(g) LICENSURE Responsibility of licensee.:

(g) A facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the resident ' s health and safety are jeopardized.

Observations:

Based on a review of the facility's outstanding accounts payable and interviews with staff, it was determined the facility failed to pay, in a timely manner, bills incurred in the operation of the facility, that are not in dispute and are for services without which the residents' health and safety are jeopardized.

Findings include:

During an interview on July 15, 2026, at 11:14 AM, the Nursing Home Administrator (NHA) stated the facility forwarded invoices to the corporate office for payment and that payment of outstanding bills was not completed at the facility level.

A review of the facility's accounts payable aging report (a financial report that categorizes unpaid invoices based on the length of time they have remained outstanding) conducted during the survey ending July 15, 2026, revealed multiple unpaid balances for vendors providing goods and services necessary for facility operations. The report identified outstanding invoices that remained unpaid for periods exceeding 181 days and, for most vendors, more than 211 days.

The aging report identified the following unpaid balances:

Vendor #1 Pharmacy services: $34,758.00, outstanding for more than 211 days.

Vendor #2 Food service: $486.49, outstanding for more than 181 days.

Vendor #3 Resident transportation services: $2,314.00, outstanding for more than 211 days.

Vendor #4 Agency staffing services: $3,986.64, outstanding for more than 211 days.

Vendor #5 Heating, ventilation, and air conditioning (HVAC) services: $21,331.15, outstanding for more than 211 days.

Vendor #6 Intravenous (IV) therapy services: $15,076.82, outstanding for more than 211 days.

Vendor #7 Respiratory therapy services: $15,134.02, outstanding for more than 211 days.

During an interview with the Nursing Home Administrator and the Director of Nursing on July 15, 2026, at 3:15 PM, the facility was unable to provide evidence that the outstanding invoices for the above goods and services had been paid in a timely manner.

Plan of Correction - To be completed: 08/07/2026

1. Corrective action for affected resident (s): Although no residents were identified as experiencing harm or interruption of services, the facility immediately initiated corrective actions.

2. How other residents were identified: Facility has not experienced on hold for services or disruption in services that would cause ill effects to any resident.

3. Systemic changes: RDO will educate NHA on AP process to ensure there is no disruption in service. Monthly Aging report will be obtained from AP and reviewed by the Administrator to ensure progress in payment to vendors.

4. Monitoring/QAPI: Designee will audit Verify that vendor invoices are reviewed and paid timely to prevent interruption of services essential to resident health and safety monthly; QAPI review monthly.

Completion Date: 8/7

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