Inspection·August 14, 2024

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to timely follow-up with required dental services for one Medicaid payor source resident out of two residents sampled (Resident 49). Residents Affected - Few Findings include: A clinical record review revealed Resident 49 was admitted to the facility on [DATE], with diagnoses that include chronic obstructive pulmonary disease (COPD), atrial fibrillation (a condition that causes the heart to beat irregularly and sometimes much faster than normal), chronic kidney disease, and dysphagia (difficulty swallowing). Review of an Annual Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated April 15, 2024, revealed that Resident 49 was moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 7-12 equates to being moderately cognitively impaired). A review of facility document entitled Inventory of personal effects dated May 24, 2021, indicated the resident had full upper and lower dentures. A review of Resident 49's care plan, initiated May 24, 2021, revealed she has an activity of daily living (ADL) self care performance deficit related to immobility, with planned interventions to include personal hygiene/oral care, resident requires 1 staff member participation with personal hygiene and oral care. (However, the care plan made no indication of the resident having, or had dentures) A review of facility provided Dental Consult Sheet dated February 23, 2023, indicating resident has dentures, no problems. A review of facility provided Dental Consult Sheet dated April 30, 2024, indicated resident has total upper (TU) in place. Lost total lower (TL) - wants new total lower (TL). Recommendations, full lower dentures. A review of nursing note dated May 1, 2024, at 9:31 AM revealed dental exam complete, no new orders (NNOS). Review of resident 49's Nutritional Risk Assessment's dated April 17, May 2, and June 27, 2024, revealed the resident's diet order was regular/regular texture/thin liquids, and makes no indication of (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395456 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Wyoming Valley 50 N. Pennsylvania Ave. Wilkes Barre, PA 18701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)