13 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Wilkes-Barre, PA
1-star overall rating with 1-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
101 East Mountain Drive, Wilkes-Barre, PA
(570) 825-5892
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Embassy Healthcare
Operator or chain grouping
Approved since
1985-10-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.63
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
8,579
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.29
Baseline 21.35% · Performance 19.44% · Measure score 4.29 · Achievement 4.29 · Improvement 3.91
Healthcare-associated infections
2.97
Baseline 8.89% · Performance 7.54% · Measure score 2.97 · Achievement 0.98 · Improvement 2.97
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0.63
Baseline 3 hours · Performance 3.26 hours · Measure score 0.63 · Achievement 0.63 · Improvement 0.41
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 8.59% · Lower 95% interval 7.1% |
| Discharge to community | 47.18% |
50.57%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 141 · Observed rate 40.43% · Lower 95% interval 40.15% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.18% |
95.27%
3.9 pts better
|
Numerator 121 · Denominator 122 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 122 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 36 · Denominator 81 |
| Discharge mobility score | 35.8% |
50.94%
15.1 pts worse
|
Numerator 29 · Denominator 81 |
| Pressure ulcers or injuries, new or worsened | 0.82% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 122 · Adjusted rate 0.74% |
| Healthcare-associated infections requiring hospitalization | 7.54% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 9% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 1.77% |
8.2%
6.4 pts worse
|
Numerator 2 · Denominator 113 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 34.57% |
56.45%
21.9 pts worse
|
Numerator 28 · Denominator 81 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 54 · Denominator 54 |
| Resident COVID-19 vaccinations up to date | 13.16% |
25.2%
12 pts worse
|
Numerator 10 · Denominator 76 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.7
0.3 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.5% |
86.9%
5.6 pts better
|
93.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.2% · Q2 91.1% · Q3 96.2% · Q4 86.7% · 4Q avg 92.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.5% |
93.5%
6 pts worse
|
95.5%
8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.2%
1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.3% · Q3 2.5% · Q4 2.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
6.5%
4.5 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.7% · Q3 2.5% · Q4 1.3% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
6.5%
1 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 11.4% · Q3 13.3% · Q4 3.9% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
19.9%
9.8 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 6.8% · Q3 9.0% · Q4 12.5% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.4% |
18.7%
1.7 pts worse
|
16.7%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 17.5% · Q3 20.3% · Q4 23.8% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.5% |
19.6%
4.1 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 16.9% · Q3 12.3% · Q4 9.0% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
18.3%
2 pts better
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 21.5% · Q3 8.6% · Q4 8.2% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.1% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
26.4%
1.5 pts better
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 24.1% · Q3 21.1% · Q4 26.4% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.3%
2.8 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 2.7% · Q4 1.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.5% |
68.9%
4.6 pts better
|
81.7%
8.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.2% · Q2 68.2% · Q3 81.9% · Q4 76.9% · 4Q avg 73.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
9.8%
3 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.9% · Q4 3.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.1% |
68.7%
9.4 pts better
|
79.7%
1.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
23.1%
2.3 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 21.2% · Expected 24.2% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2026-02-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-09
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2026-02-09
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-02-09
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-09
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-05
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-05-05
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-05
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-05-05
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-05
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-05
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-01
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-01
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-01
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-01
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-01
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-20
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2026-02-20
Health
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.
Corrected 2026-02-20
Health
Provide activities to meet all resident's needs.
Corrected 2026-02-20
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2026-02-20
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2026-02-20
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2026-02-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-20
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2026-02-20
Health
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.
Corrected 2026-02-21
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-20
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-18
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-06-05
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-04-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-11
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-11
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-11
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2025-04-11
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-11
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-04-11
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-04-11
Health
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.
Corrected 2025-04-11
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-04-11
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-04-11
Health
Provide or obtain dental services for each resident.
Corrected 2025-04-11
Health
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.
Corrected 2025-04-11
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-05-21
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-21
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-21
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-21
Health
Assess the resident when there is a significant change in condition
Corrected 2024-05-21
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-05-21
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-21
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-05-21
Health
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.
Corrected 2024-02-20
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-20
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-20
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-30
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-07-06
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-06
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Nearby options
Wilkes-Barre, PA
5-star overall rating with 4-star inspections with 2 recent health deficiencies
Pittston, PA
2-star overall rating with 3-star inspections with $8,021 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Wilkes-Barre, PA
2-star overall rating with 2-star inspections with abuse icon flag with $8,278 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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