Cycle 1
Health 2025-07-25 · Fire 2025-07-25
19 health deficiencies
Top issue: Resident Rights (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Scranton, PA
Embassy Of Scranton
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $18,769 in total fines with 19 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
824 Adams Avenue, Scranton, PA
(570) 346-5704
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
139
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Embassy Healthcare
Operator or chain grouping
Approved since
1969-10-31
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
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,091
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
2.51
Performance 7.08% · Measure score 2.51 · Achievement 2.51 · This facility did not have sufficient data to calculate a baseline period measure result.
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
1.10
Baseline 3.27 hours · Performance 3.39 hours · Measure score 1.10 · Achievement 1.10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.73% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 56 · Observed rate 12.5% · Lower 95% interval 7% |
| Discharge to community | 48.33% |
50.57%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 31.37% · Lower 95% interval 33.46% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 42.31% |
95.27%
53 pts worse
|
Numerator 11 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 26 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 2.4% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 125 |
| Staff flu vaccination coverage | 9.3% |
42%
32.7 pts worse
|
Numerator 20 · Denominator 215 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.7
1.2 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
86.9%
10.6 pts better
|
93.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 96.2% · Q3 98.8% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
93.5%
5.3 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.2%
2.2 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 0.0% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
6.5%
6.2 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 10.4% |
6.5%
3.9 pts worse
|
5.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 10.6% · Q3 9.3% · Q4 8.2% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
19.9%
1.1 pts better
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 20.6% · Q3 18.2% · Q4 14.7% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
18.7%
3.2 pts better
|
16.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 11.1% · Q3 14.0% · Q4 17.3% · 4Q avg 15.5% · 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 | 29.2% |
19.6%
9.6 pts worse
|
16.3%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 46.6% · Q3 31.1% · Q4 17.0% · 4Q avg 29.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
18.3%
2.4 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 32.3% · Q3 16.7% · Q4 13.0% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.9%
0.6 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.9% · Q4 3.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.7%
0.2 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 3.8% · Q4 1.3% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
26.4%
0.3 pts better
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 31.5% · Q3 13.2% · Q4 39.3% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.3%
1.1 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.4% · Q3 3.4% · Q4 8.9% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.0% |
68.9%
2.1 pts better
|
81.7%
10.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 58.3% · Q3 97.9% · Q4 85.0% · 4Q avg 71.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.1% |
9.8%
6.7 pts better
|
12.0%
8.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.1% · Observed 3.3% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
1.5%
3.9 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 9.5% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.8% |
68.7%
9.1 pts better
|
79.7%
1.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.3% |
23.1%
4.2 pts worse
|
23.9%
3.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.3% · Observed 30.0% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-06 · Fire 2024-09-06
24 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
12 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-10-20 · Fire 2023-10-20
34 health deficiencies
Top issue: Nutrition and Dietary (8 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-07-25
K321 · Smoke Deficiencies
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 2025-08-26
E · Potential for more than minimal harm
2025-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-07-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-26
C · Minimal harm
2025-07-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-26
C · Minimal harm
2025-07-25
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-08-26
E · Potential for more than minimal harm
2024-09-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-06
K223 · Egress Deficiencies
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 2024-10-22
E · Potential for more than minimal harm
2024-09-06
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-06
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-09-06
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-10-22
C · Minimal harm
2024-09-06
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-10-22
C · Minimal harm
2024-09-06
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-10-22
C · Minimal harm
2024-09-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-22
E · Potential for more than minimal harm
2023-10-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-20
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-20
K321 · Smoke Deficiencies
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 2023-12-19
E · Potential for more than minimal harm
2023-10-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-19
E · Potential for more than minimal harm
2023-10-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-12-19
C · Minimal harm
2023-10-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-19
C · Minimal harm
2023-10-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-19
C · Minimal harm
2023-10-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-19
C · Minimal harm
2023-10-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-19
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-03-02
D · Potential for more than minimal harm
2026-01-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-03-02
D · Potential for more than minimal harm
2026-01-28
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2026-03-02
F · Potential for more than minimal harm
2025-07-25
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-09-24
F · Potential for more than minimal harm
2025-07-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-07-25
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-09-24
E · Potential for more than minimal harm
2025-07-25
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-24
E · Potential for more than minimal harm
2025-07-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-24
E · Potential for more than minimal harm
2025-07-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-09-24
E · Potential for more than minimal harm
2025-07-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-09-24
E · Potential for more than minimal harm
2025-07-25
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-07-25
F584 · Resident Rights Deficiencies
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 2025-10-03
D · Potential for more than minimal harm
2025-07-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-07-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-07-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-24
D · Potential for more than minimal harm
2025-07-25
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-09-24
B · Minimal harm
2025-07-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-09-24
E · Potential for more than minimal harm
2025-04-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-04-01
F584 · Resident Rights Deficiencies
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 2025-04-29
E · Potential for more than minimal harm
2024-09-06
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-06
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-09-06
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-06
F761 · Pharmacy Service Deficiencies
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 2024-11-01
E · Potential for more than minimal harm
2024-09-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-06
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-06
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-09-06
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-09-06
F657 · Resident Assessment and Care Planning Deficiencies
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 2024-11-01
D · Potential for more than minimal harm
2024-09-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-09
D · Potential for more than minimal harm
2024-09-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-09-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-09-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-09-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-12-13
C · Minimal harm
2024-09-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-08-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-08-09
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-08-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-08-09
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-08-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-02-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-02-14
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-16
F · Potential for more than minimal harm
2024-01-04
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-02-14
F · Potential for more than minimal harm
2024-01-04
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-04
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-16
E · Potential for more than minimal harm
2024-01-04
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-14
E · Potential for more than minimal harm
2024-01-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-14
D · Potential for more than minimal harm
2024-01-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-10-20
F801 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-10-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-10-20
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-10-20
F584 · Resident Rights Deficiencies
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 2024-01-04
E · Potential for more than minimal harm
2023-10-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-10-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-10-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-16
E · Potential for more than minimal harm
2023-10-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-10-20
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-10-20
F761 · Pharmacy Service Deficiencies
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 2024-01-04
E · Potential for more than minimal harm
2023-10-20
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-10-20
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-10-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-10-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-10-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-10-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-10-20
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-10-20
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-10-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-10-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-10-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-10-20
F849 · Administration Deficiencies
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 2024-01-04
B · Minimal harm
2023-10-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-04
G · Actual harm
2023-08-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-13
Penalties and ownership
What sits behind the stars
$0
2024-08-09
Payment Denial
Payment Denial · denial start 2024-11-09 · 61 days
61 day denial
$0
2023-10-20
Payment Denial
Payment Denial · denial start 2024-02-29 · 47 days
47 day denial
$18,769
2023-08-09
Fine
Fine · fine $18,769
Fine
Ownership
Embassy Healthcare Holdings Inc
5% Or Greater Direct Ownership Interest · Organization
2020 Gsr Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Aaron Handler Family Dynasty Trust
5% Or Greater Indirect Ownership Interest · Organization
Aaron Handler Revocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Ah Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
George S. Repchick 2020 Family Dynasty Trust
5% Or Greater Indirect Ownership Interest · Organization
Handler, Aaron
Operational/Managerial Control · Individual
Moran, Michael
Operational/Managerial Control · Individual
Repchick, George
Operational/Managerial Control · Individual
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