Pennsylvania Department of Health
EMBASSY OF WYOMING VALLEY
Patient Care Inspection Results

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EMBASSY OF WYOMING VALLEY
Inspection Results For:

There are  137 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
EMBASSY OF WYOMING VALLEY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit survey completed on May 16, 2025, it was determined that Embassy of Wyoming Valley corrected the federal deficiencies cited during the survey of March 14, 2025, under 42 CFR Part 483 Subpart B Requirements for Long Term Care but was out of compliance under the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


§ 211.12(f.1)(3) LICENSURE Nursing services. :State only Deficiency.
(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 8 shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:10 on the day shift and 1:11 on the evening shift based on the facility's census.

May 9, 2025 - 7.07 nurse aides on the evening shift, versus the required 8.27 for a census of 91.
May 10, 2025 - 6.93 nurse aides on the day shift, versus the required 8.90 for a census of 89.
May 11, 2025 - 7.00 nurse aides on the day shift, versus the required 8.80 for a census of 88.
May 11, 2025 - 5.60 nurse aides on the evening shift, versus the required 8.00 for a census of 88.
May 12, 2025 - 7.73 nurse aides on the day shift, versus the required 8.70 for a census of 87.
May 13, 2025 - 7.67 nurse aides on the day shift, versus the required 8.70 for a census of 87.
May 15, 2025 - 8.67 nurse aides on the day shift, versus the required 8.70 for a census of 87.
May 15, 2025 - 6.80 nurse aides on the evening shift, versus the required 7.91 for a census of 87.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Director of Nursing on May 16, 2025, at 1:50 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.



 Plan of Correction - To be completed: 06/19/2025

Facility cannot retroactively correct this deficiency.

Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff may be utilized for open shifts if available.

Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff.

The Director of Nursing/designee will review the ratio daily for compliance.
All efforts will be made to meet certified aide staffing ratios. If a call off occurs all efforts will be made to fill that position.

The Director of Nursing/designee will audit the certified aide ratio 1x/week for 4 weeks then monthly for 2 months.
Results of the audits will be presented to the QA committee for review and recommendation.

§ 211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on a review of nurse staffing and staff interview, it was determined the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for 2 shifts out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:30 on the evening shift and 1:40 on the night shift based on the facility's census.

May 10, 2025 - 2.63 LPNs on the evening shift, versus the required 2.97 for a census of 89.
May 10, 2025 - 2.00 LPNs on the night shift, versus the required 2.23 for a census of 89.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Director of Nursing on May 16, 2025, at 1:50 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.




 Plan of Correction - To be completed: 06/19/2025

Facility cannot retroactively correct this deficiency.

Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff may be utilized for open shifts if available.

Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff.

Labor meeting occurs daily and attended by NHA, DON, HRD, and scheduler. Agenda includes reviewing HPPD and ratios from the prior day, current day, and next day to ensure the ratio HPPD are met and sustained over time.

The Director of Nursing/designee will audit the ratio 1x/week for 4 weeks then monthly for 2 months.


All efforts will be made to meet LPN's ratios. If a call off occurs all efforts will be made to fill that position.

Labor meeting minutes will be submitted to the QAPI committee to include daily HPPD, ratios, and staff calloffs. Minutes will be submitted for 2 month to ensure deficient practice does not recur.

§ 211.12(i)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Findings include:

A review of the facility's staffing levels revealed that on the following dates the facility failed to provide minimum nurse staffing of 3.2 hours of general nursing care to each resident:
May 10, 2025 - 2.86 direct care nursing hours per resident.
May 11, 2025 - 3.05 direct care nursing hours per resident.

The facility's general nursing hours were below minimum required levels on the dates noted above.

An interview with the Director of Nursing on May 16, 2025, at 1:50 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.



 Plan of Correction - To be completed: 06/19/2025

The Facility cannot retroactively correct this deficiency.

Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff may be utilized for open shifts if available.
Retention efforts will be made in earnest.

Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all nursing staff.

The Director of Nursing/designee will review the PPD daily for compliance. All efforts will be made to meet the required PPD of 3.2. If a call off occurs all efforts will be made to achieve the PPD.

The Director of Nursing/designee will audit the PPD 1x/week for 4 weeks then monthly for 2 months.
Results of the audit will be presented to the QA committee for review and recommendation


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