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Deficiency Records for Embassy of Scranton
A list of the most recent deficiencies for Embassy of Scranton. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Embassy of Scranton. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-14 | 2024-04-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-02-14 | 2024-04-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-04 | 2024-04-16 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-20 | 2024-04-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-04 | 2024-02-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-04 | 2024-02-14 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-01-04 | 2024-02-14 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-01-04 | 2024-02-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-01-04 | 2024-02-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-04 | 2024-02-14 | Y |
| Keep all essential equipment working safely. | Health | 2024-01-04 | 2024-02-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-20 | 2024-02-14 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-10-20 | 2024-02-14 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-10-20 | 2024-02-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-20 | 2024-02-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-20 | 2024-02-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-20 | 2024-01-04 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-10-20 | 2024-01-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-20 | 2024-01-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-10-20 | 2024-01-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-20 | 2024-01-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-10-20 | 2024-01-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-20 | 2024-01-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-20 | 2024-01-04 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-20 | 2024-01-04 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-10-20 | 2024-01-04 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-10-20 | 2024-01-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-20 | 2024-01-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-20 | 2024-01-04 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-20 | 2024-01-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-20 | 2024-01-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-20 | 2024-01-04 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-10-20 | 2024-01-04 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-10 | 2023-01-27 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-11-10 | 2023-01-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-10 | 2023-01-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-10 | 2023-01-27 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-10 | 2023-01-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-10 | 2023-01-04 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-11-10 | 2023-01-04 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-11-10 | 2023-01-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-10 | 2023-01-04 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-11-10 | 2023-01-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-10 | 2023-01-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-10 | 2023-01-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-10 | 2023-01-04 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-11-28 | 2022-12-27 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-11-28 | 2022-12-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-28 | 2022-12-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-28 | 2022-12-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-28 | 2022-12-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-11-28 | 2022-12-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-07 | 2022-05-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-01-07 | 2022-05-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-07 | 2022-05-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-07 | 2022-04-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-07 | 2022-04-06 | N |
| Respond appropriately to all alleged violations. | Health | 2022-01-07 | 2022-04-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-07 | 2022-04-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-07 | 2022-04-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-01-07 | 2022-03-10 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-01-07 | 2022-03-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-07 | 2022-03-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-01-07 | 2022-03-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-01-07 | 2022-03-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-07 | 2022-03-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-07 | 2022-03-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-01-07 | 2022-03-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-07 | 2022-03-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-07 | 2022-03-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-01-07 | 2022-03-10 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-07 | 2022-03-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-01-07 | 2022-03-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-01-07 | 2022-03-10 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-07 | 2022-03-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-07 | 2022-03-10 | N |
| Use approved construction type or materials. | Fire Safety | 2022-01-11 | 2022-02-02 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-01-11 | 2022-02-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-01-11 | 2022-02-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-11 | 2022-02-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-09 | Not Fixed | Y |
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