Embassy of Scranton

Inspectors wroteBased on staff interviews, review of personnel records, employee credentials, facility documentation, and dietary service records, it was determined the facility failed to ensure the food and nutrition services department received the required oversight by qualified personnel after the resignation of the facility's Registered Dietitian (RD).

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased on clinical record review, facility policy review, external wound care records, hospital records, and staff and family interviews, it was determined the facility failed to provide necessary treatment and services consistent with professional standards of practice to assess, monitor, and treat an existing pressure injury for one of 10 residents reviewed (Resident 1) resulting in actual harm.

Inspectors wroteBased on a clinical record review and staff interview, it was determined the facility failed to ensure that the required resident information was communicated to the receiving health care provider for two out of 10 residents reviewed (Residents 1 and 2).

Inspectors wroteBased on clinical record review, documentation review, resident representative interview, and staff interview, , it was determined the facility failed to ensure that a resident who was dependent on staff for assistance with activities of daily living (ADLs) consistently received necessary care and services to maintain personal hygiene and dignity for one resident out of 10 sampled residents (Resident 1).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to develop, communicate, and implement an individualized toileting and bowel incontinence management program for one of 10 residents reviewed (Resident 1). The facility failed to establish interventions to ensure timely toileting assistance, routine monitoring for bowel incontinence, and prompt incontinence care for a resident assessed as completely dependent on staff for toileting and always incontinent of bowel.

Inspectors wroteBased on clinical record review, facility policy review, observations, and staff interviews, it was determined the facility failed to implement individualized, person-centered interventions identified in the care plan to address dementia-related behaviors for one of seven sampled residents (Resident 3).

Inspectors wroteBased on review of clinical records, hospital records, physician orders, and staff interviews, it was determined the facility failed to ensure physician-ordered laboratory services were obtained in a timely manner and failed to follow through on ordered laboratory testing for one of seven residents reviewed (Resident 4).

Inspectors wroteBased on staff interviews, review of personnel records, employee credentials, facility documentation, and dietary service records, it was determined that the facility failed to ensure the registered dietitian (RD) provided the required on-site oversight of the food and nutrition services department.

Inspectors wroteBased on review of facility policies, facility records, observations, and resident and staff interviews, it was determined the facility failed to ensure meals were prepared and served in accordance with the planned menu, failed to provide nutritionally comparable substitutions when menu items were unavailable, failed to document and review substitutions by a Registered Dietitian and failed to notify residents of menu changes for seven of 22 residents interviewed (Residents 11, 15, 39, 59, 60, 74, and 76).

Inspectors wroteBased on observations, resident and staff interview, and test tray results, it was determined that the facility failed to ensure meals were served in a palatable and visually appealing manner and at safe and appetizing temperatures during in-room meal service for two test trays observed on the second and third floors during lunch meal service. (Residents 11, 15, 59, 60, 74, 76, 39, 30).

Inspectors wroteBased 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 and in one out of two resident nourishment room areas (second floor).

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to maintain a clean, sanitary, functional, and comfortable environment on one of three resident floors reviewed, the first floor, which remained licensed and available for resident occupancy.

Inspectors wroteBased on clinical record review, review of facility policies, care plan documentation, and staff interviews, it was determined the facility failed to ensure comprehensive care plans were reviewed, revised, and discussed with residents and/or resident representatives following Minimum Data Set (MDS) assessments for three of 22 residents reviewed (Resident 4, Resident 9, and Resident 58).

Inspectors wroteBased on clinical record review, review of facility policy, weight records, nutritional documentation, and staff interviews, it was determined the facility failed to consistently monitor resident weights, ensure accurate and timely weight tracking, and timely implement nutritional interventions to address significant weight loss for two (2) of twenty-two (22) residents reviewed (Residents 30 and 5).

Inspectors wroteBased on observation, select facility policy review, and staff interviews, it was determined the facility failed to implement and adhere to procedures to ensure acceptable storage and use-by dates for multi-dose medications in two of two medication rooms (Second floor medication room and third floor medication room).

Inspectors wroteBased on a review of select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by four of six residents participating in a group interview (Residents 15, 11, 59, and 74).

Inspectors wroteBased 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.

Inspectors wroteBased on review of the Centers for Disease Control and Prevention (CDC) guidance, facility policy, clinical records, observations, and staff interviews, it was determined the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the potential spread of infection for two of 22 residents reviewed (Residents 9 and 34).

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined the facility failed to maintain the privacy and confidentiality of residents' medical information and treatment during dental examinations on one of three clinical environments reviewed (Resident 12, Resident 28, and Resident 47).

Inspectors wroteBased 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).

Inspectors wroteBased on a review of facility investigative documentation, clinical records, hospital records, and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure licensed nursing staff timely assessed, monitored, evaluated, documented, and responded to a resident's condition following a witnessed fall event for one (1) of twenty-two (22) sampled residents reviewed (Resident 91).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined the facility failed to ensure a resident received necessary assistive devices and assistance to maintain vision abilities for one of 22 residents reviewed (Resident 28).

Inspectors wroteBased on clinical record review, review of select facility policy, and staff interviews, it was determined the facility failed to consistently implement a planned restorative nursing program to maintain mobility and functional abilities to the extent possible for one of 22 residents reviewed (Resident 5).

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to maintain an environment free from accident hazards related to unsafe electrical connections and improper use of extension cords and power strips for resident care equipment and electrical devices in three resident rooms reviewed (Rooms 321 Bed 2, 308 Bed 2, and 306 Bed B).

Inspectors wroteBased on review of clinical records, facility policy, nutritional documentation, observations, and staff interviews, it was determined that the facility failed to provide care and services for a resident receiving enteral nutrition (nutrition provided through a feeding tube) to prevent significant weight loss and ensure adequate nutritional support for 1 of 1 resident reviewed for feeding tube management (Resident 10).

Inspectors wroteBased on clinical record review, review of psychiatric consultation documentation, resident and staff interviews, and review of facility interventions, it was determined the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one of 22 residents reviewed (Resident 28).

Inspectors wroteBased 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).

Inspectors wroteBased on observations, resident and staff interviews, and facility documentation review, it was determined the facility failed to maintain a safe, comfortable, and functional environment by failing to ensure four Packaged Terminal Air Conditioner (PTAC) units were operational within resident care areas of the facility, including one resident out of 22 reviewed (Resident 39).

Inspectors wroteBased on review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to complete a comprehensive admission and readmission evaluation and failed to ensure physician diet orders were accurate, verified, and consistent with the resident's assessed swallowing needs and interdisciplinary care planning process for one of three residents reviewed with swallowing deficits (Resident 8).

Inspectors wroteBased on observation, clinical record review, review of resident council meeting minutes and grievances, and interviews with residents and staff, , the facility failed to reasonably accommodate a resident's need to obtain staff assistance by failing to ensure the resident had access to a call bell to request help by failing to ensure the call bell was available preventing the resident from independently notifying staff when assistance was needed for 1 of 10 residents observed (Resident 1).

Inspectors wroteBased on observations, review of clinical records, facility policies, facility investigative documentation, video surveillance, and resident and staff interviews, it was determined the facility failed to ensure that the environment remained as free of accident hazards as possible and failed to provide adequate supervision and environmental safety to prevent an avoidable accident. This failure placed one of eight residents reviewed (Resident 1) in Immediate Jeopardy to their health and safety due to the high likelihood of serious injury or death from falls or self-harm.

Inspectors wroteBased on observation, clinical record review, review of resident council meeting minutes and grievances, and interviews with residents and staff, , the facility failed to reasonably accommodate a resident's need to obtain staff assistance by failing to ensure the resident had access to a call bell to request help by failing to ensure the call bell was available preventing the resident from independently notifying staff when assistance was needed for 1 of 10 residents observed (Resident 1).

Inspectors wroteBased on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to implement procedures to ensure the accurate administration of prescribed medications for one of eight sampled residents (Resident 1).

Inspectors wroteBased on a review of clinical records, employee job descriptions, and staff interviews, the facility's administration, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), failed to effectively manage facility operations to ensure resident safety and to maintain the highest practicable physical and mental well-being of residents. This failure occurred because the facility did not ensure the environment was maintained as free of accident hazards as possible, did not ensure adequate supervision and environmental safety, and did not ensure appropriate management of a resident's psychiatric care and medication regimen for one of eight residents sampled (Resident 1), who was able to exit the facility through a second-floor window and landed on a porch into the snow. This failure resulted in Immediate Jeopardy to resident health and safety.

Inspectors wroteBased on a review of select facility policy and resident and staff interviews, it was determined the facility failed to ensure that fresh drinking water was consistently readily accessible to residents to promote adequate hydration, meet resident preferences, and maintain their comfort for six of 22 residents reviewed (Residents 78, 21, 30, 5, 65, and 9).

Inspectors wroteBased on observation and staff interview, it was determined 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 and in two out of two resident pantry areas located on second and third floor.

Inspectors wroteBased on a review of select facility policy, facility grievance forms, resident interviews, staff interviews, and observations it was determined the facility failed to make ongoing efforts to resolve grievances and provide timely follow up with residents regarding the status update on the resolution process of call bell response times for 8 of 22 residents interviewed (Resident 5, 9,13 ,21 , 30, 45 ,65,78).

Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, were completed for two of three discharged residents reviewed (Residents 96, and 98). A review of Resident 96's clinical record revealed that he was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (ME) are brain dysfunctions due to problems with metabolism, or the body's chemical processes that turn food into energy and filter out harmful toxins), transient cerebral ischemic attacks (TIA - is a short period of symptoms similar to those of a stroke and caused by a brief blockage of blood flow to the brain), and weakness. [...]

Inspectors wroteBased on observations, a review of clinical records, review of facility policies, and facility provided investigative documentation, and staff interviews, it was determined the facility failed to provide adequate staff supervision to a resident identified at risk of elopement to prevent unsupervised exits from the facility for one resident (Resident 74) and failed to provide supervision to prevent a fall for one resident ( Resident 35) out of 22 residents sampled.

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the physician failed to act upon pharmacist identified irregularities in the medication regimen for one of twenty-two residents sampled (Resident 30).

Inspectors wroteBased on a review of clinical records, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 22 residents sampled (Resident 8).

Inspectors wroteBased on observations, and staff and resident interviews, it was determined the facility failed to ensure that essential equipment, it was determined that essential equipment for the mechanical preparation of ice was not being maintained in a safe operating condition.

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment and resident care equipment for one of two residents receiving enteral tube feeding. (Resident101)

Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interview, it was determined the facility failed to protect one of 23 sampled residents (Resident 9) from neglect.

Inspectors wroteBased on a review of clinical records, the facility's abuse neglect and exploitation policy, information provided by the facility, and staff interviews, it was determined that the facility failed to promptly conduct a thorough investigation to rule out abuse and implement corrective action for one of 22 residents reviewed (Resident 9).

Inspectors wroteBased on clinical record review and select facility policy, staff interview, and review of facility documentation, it was determined the facility failed to ensure that a resident who is unable to maintain adequate nutrition and hydration status received appropriate nutritional support, physician notification, and timely interdisciplinary assessment to prevent further nutritional decline for one of 21 residents reviewed (Resident 76).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered care plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for one out of 22 residents reviewed. [...]

Inspectors wroteBased on clinical record review, facility provided documentation and staff interviews, it was determined the facility failed to timely provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to notify one of three residents reviewed (Resident CR-1) that Medicare Part A coverage for skilled nursing services was ending. Findings Include: A review of Resident CR-1's clinical record revealed admission to the facility on February 12, 2025, with diagnoses to include weakness and need for personal assistance. Review of the resident's Medicare coverage documentation revealed the last day of covered Medicare Part A services was February 18, 2025. [...]

Inspectors wroteBased on observation, review of facility policy, test tray results, and interviews with staff and residents, the facility failed to serve meals that were palatable and maintained at a safe and appetizing temperature for 6 of 10 residents sampled (Residents 2, 3, 5, 6, 7, and 8).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to maintain a safe, clean, and homelike environment in two areas of the facility (the kitchen entrance door and the laundry room entrance door), affecting the safety and security of the environment for both staff and residents.

Inspectors wroteBased on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by four residents attending a resident group meeting (Residents 46, 57, 16, and 35) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution.

Inspectors wroteBased on observations, review of select facility policy, and staff interviews, it was determined the facility failed to develop a comprehensive grievance policy and ensure the necessary information for filing a grievance was posted and/or provided/available to residents or their representatives.

Inspectors wroteBased on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for one of 6 residents reviewed. (Resident A1).

Inspectors wroteBased on a review of clinical records and select facility policy and staff interview, it was determined the facility failed to timely respond to a resident's increased level of pain and provide an effective pain management to alleviate pain for four residents of 18 residents sampled (Residents 17, 3, 41, and 18).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure adherence to medication expiration/use by dates on two of four medication carts (Second Floor - Long hall and Short hall).

Inspectors wroteBased on observations, resident and staff interview, and test tray results, it was determined the facility failed to serve meals that are palatable, attractive, and at safe and appetizing temperature for two of the 18 residents sampled (Resident 44 and 6) and including experiences reported by 4 out of four residents during a group interview (Residents 46, 57, 16, and 35).

Inspectors wroteBased on a review of clinical records and the facility's planned cycle menu, observation and staff and resident interviews it was determined that the facility failed to provide therapeutic diets prescribed by resident's attending physician for two residents out of 18 sampled (Resident 3 and 44).

Inspectors wroteBased on review of facility QAPI meeting attendance records and staff interviews, it was determined the facility failed to ensure that the required committee members met at least quarterly for one quarter out of three reviewed.

Inspectors wroteBased on a review of select facility policy, review of Center for Medicare and Medicaid services memo, a review of ASHRAE guidelines for Legionella, review of facility documentation, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for twelve of twelve months (August 2023 through August 2024). Findings Include: [...]

Inspectors wroteBased on review of regulations, facility policy review, and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility. Findings Include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP must work at least part-time at the facility, physically work onsite in the facility, cannot be an off-site consultant, or perform the IP work at a separate location. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 5, 2024, at 11:40 AM, they stated that the prior IP left the role in the beginning of August 2024, and there was currently no designated IP. [...]

Inspectors wroteBased on review of select facility policy, and resident and staff interviews, it was determined the facility failed to provide an environment, which promotes each resident's quality of life by failing to accommodate cognitively intact resident's snack cart for four residents out of four sampled residents (Residents 46, 57, 16, and 35).

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one resident out 6 sampled (Resident B1).

Inspectors wroteBased on review of select facility policy and interviews with residents and staff, it was determined the facility failed to review and revise the resident's plan of care in response to a significant weight loss for one resident out 18 residents (Resident 66).

Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 16 residents reviewed (Residents 51).

Inspectors wroteBased on observation, select facility policy review and staff interview it was determined the facility failed to maintain an environment free of potential accident hazards during medication administration on one of two resident care units. (second floor) for one of two residents observed.

Inspectors wroteBased on a review of select facility policy, and clinical records, and staff interview, it was determined the facility failed to thoroughly assess and evaluate bowel function and implement individualized approaches to restore normal bowel function to the extent possible for one out of 6 sampled residents (Resident A2).

Inspectors wroteBased on a review of clinical records, observations and staff interviews it was determined that the facility failed to provide pharmacy services, routine drugs and pharmaceuticals, to ensure timely medication administration as prescribed for one resident out of 18 sampled (Resident 180) and maintain accurate narcotic administration records for one resident out of 18 sampled (Resident 18).

Inspectors wroteBased on a review clinical record, facility provided documents, the facility's plan of correction from the surveys ending on August 9, 2024, and on September 6, 2024, and the outcome of the activities of the facility's quality assurance committee it was determined the facility failed to develop and implement a quality assurance plan, which was able to identify, and correct ongoing quality deficiencies related to the assessment and implementation of bowel and bladder programs for one of 6 residents sampled (Resident A2).

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to correctly post nurse staffing information.

Inspectors wroteBased on a review of clinical records, select facility policy facility documentation, and staff interview, it was determined the facility failed to ensure that three residents out of 6 sampled were free from physical abuse (Residents 2, 3 and 4).

Inspectors wroteBased on review of clinical records, facility policy provided to residents upon transfer from the facility, and interview with facility staff revealed the facility failed to demonstrate the implementation of specifically delineated procedures for Medicaid payor source bed holds and the provision of notices of the facility's bed hold policy in an understandable language that allow a resident to return to the facility after a transfer to the emergency room for one resident out of six reviewed. (Resident 5).

Inspectors wroteBased on a review of select facility policy, and clinical records, and staff interview, it was determined the facility failed to thoroughly assess and evaluate bowel function and implement individualized approaches to restore normal bowel function to the extent possible for one out of 6 sampled residents (Resident 1).

Inspectors wroteBased on staff interviews and a review of employee personnel records it was determined that the facility failed to provide abuse prevention training to four employee out of four reviewed. (Employees 1,2,3, and 4).

Inspectors wroteBased on review of clinical records and staff interview, it was determined the facility failed to timely notify the resident's responsible representative of a change in condition for one resident out of 6 sampled (Resident 5).

Inspectors wroteBased on a review of clinical records and select facility reports and staff interviews it was determined that the facility failed to develop and implement a person-centered care plan that fully addressed a resident's behavior management, included repeated non-compliance with the facility's leave of absence policy, to consistently meet the resident's safety needs for one resident out of 10 sampled (Resident A1).

Inspectors wroteBased on observation and a review of clinical records and staff and resident interviews it was determined that the facility failed to efficiently deploy sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents in the facility, including experiences reported by four out of 10 residents sampled (Residents B1, B2, B3, and B4).

Inspectors wroteBased on staff interviews and observations it was determined that the facility failed to employ sufficient staff qualified staff to provide oversight of the food and nutrition services department.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to maintain necessary electrical equipment in safe operating condition in the kitchen.

Inspectors wroteBased on a review of nursing staffing hours and ratios, observations and resident, family and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents, in accordance with the resident's plan of care, including Resident 2.

Inspectors wroteBased on a review of clinical records and the facility's planned cycle menu, observation and staff and resident interviews it was determined that the facility failed to prepare, in advance, a nutritionally adequate menu, reflecting cultural and ethnic needs of one resident (Resident C1) and failed to follow planned menus, including the lunch meals observed served to two residents (Residents C2 and C3) out of 15 residents sampled (Resident C1).

Inspectors wroteBased on observation, resident and staff interview, test tray results, and a review of select facility policy, it was determined that the facility failed to provide meals that are served at safe and palatable temperatures.

Inspectors wroteBased on observations, review of the statement of deficiencies from the survey ending October 20, 2023, and the activities of facility's quality assurance committee and staff interviews it was determined that the facility failed to implement effective plans to correct quality deficiencies in food and nutrition services, including planned nutritionally adequate menus, sufficient qualified staff, food temperature and taste, and hydration to ensure that corrective action plans designed to improve the delivery of care and services were consistently implemented to correct and deter future quality deficiencies.

Inspectors wroteBased on a review of clinical records, the facility's abuse prohibition policy, select facility incident reports, and information submitted by the facility, and staff interview, it was determined that the facility failed to ensure that one resident out of 12 residents sampled were free from physical abuse (Resident A9).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to accurately monitor a fluid restriction prescribed to address a resident's clinical condition and maintain fluid balance and adequate hydration status for one resident (Resident B3) out of 12 sampled.

Inspectors wroteBased on review of select facility policy and minutes from Resident Council meetings and resident and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints/grievances expressed during Resident Council Meetings including those voiced by four of four residents attending a resident group meeting (Residents 55, 63, 61, and 40)

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment in resident areas on two of three resident units (Second and Third Floor Nursing Units)

Inspectors wroteBased on review of clinical records and select facility policy, and staff and resident interviews it was determined that the facility failed to provide nursing services consistent with professional standards by failing to timely and fully assess wounds for two residents (Resident 237 and 52) and to timely administer prescribed medications for one resident (Resident 237) out of 19 residents sampled.

Inspectors wroteBased on a review of nursing staffing hours and ratios, observations and resident, family and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents, in accordance with the resident's plan of care, including Resident 2.

Inspectors wroteBased on observation, resident and staff interviews and a review of meal service delivery schedule and the minutes from resident food committee meetings it was determined that the facility failed to consistently maintain sufficient staffing in the dietary department to effectively and efficiently carry out the functions of the food and nutrition service department.

Inspectors wroteBased on a review of clinical records, the facility's abuse prohibition policy, select facility incident reports, and information submitted by the facility, and staff interview, it was determined that the facility failed to ensure that one resident out of 12 residents sampled were free from physical abuse (Resident A9).

Inspectors wroteBased on a review of clinical records and select facility policies and resident and staff interviews, it was determined that the facility failed to timely and thoroughly investigate injuries of unknown source to rule out abuse, neglect or mistreatment for one of the 19 residents sampled (Resident 31).

Inspectors wroteBased on clinical record review and staff interview it was determined that the baseline care plan of one of 19 residents sampled (Resident 237) failed to fully address the resident's immediate needs upon admission.

Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to implement pharmacy procedures to promote accurate controlled medication records for one resident (Resident 86) out of 19 residents sampled.