Pennsylvania Department of Health
EMBASSY OF SCRANTON
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF SCRANTON
Inspection Results For:

There are 175 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 SCRANTON - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit and abbreviated complaint survey completed on March 5, 2026, it was determined that Embassy of Scranton corrected the federal deficiencies cited during the survey of January 28, 2026, however continued to be out of compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations:
Based on observation, clinical record review, review of resident council meeting minutes and grievances, and interviews with residents and staff, , the facility failed to reasonably accommodate a resident ' s need to obtain staff assistance by failing to ensure the resident had access to a call bell to request help by failing to ensure the call bell was available preventing the resident from independently notifying staff when assistance was needed for 1 of 10 residents observed (Resident 1).

Findings include:

A review of a facility policy titled " Call Lights: Accessibility and Timely Response " last reviewed by the facility on January 22, 2026, revealed it is the expectation of the facility staff to ensure residents have access to the call light. The policy further revealed all staff members who see or hear an activated call light are responsible for responding.

A clinical record review revealed Resident 1 was admitted to the facility on February 12, 2025, with diagnoses that included acquired absence of the left leg above knee and right leg below knee (an amputation often performed for foot and ankle problems. The amputation often leads to the use of an artificial leg that can allow a person to walk).

A review of Resident 1's annual Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 2, 2026, revealed that Resident 1 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

During an observation on March 5, 2026, at 10:00 AM, Resident 1 ' s room contained multiple bags of personal items and clothing. Resident 1 asked the surveyor to hand him the call bell. The call bell cord was observed wrapped around the undercarriage of the bed frame two times and positioned behind the resident ' s head, out of reach.

The surveyor unwrapped the cord and attempted to provide the call bell to the resident. The cord was caught under bags located behind the bed, limiting the available length. Resident 1 was required to bend his arm backward to reach the call bell due to the restricted cord length.

Interview with Resident 1 at the time of observation, revealed the resident was unable to explain how the call bell was placed on the bottom part of the bed behind his head, out of reach.

During an interview on March 5, 2026, at 11:40 AM, the Nursing Home Administrator (NHA) stated the facility previously discussed clutter in Resident 1 ' s room with the resident but the matter had not been resolved.

A review of the Resident Council meeting minutes dated February 26, 2026, revealed residents present at the meeting raised concerns regarding call bell response times. Residents reported difficulty receiving staff assistance for toileting during the 11:00 PM to 7:00 AM shift and indicated call bells were not consistently answered when residents rang for assistance. The residents in attendance included Resident 1.

A review of a grievance filed on February 26, 2026, related to call bell response concerns revealed the facility initiated call bell response audits for five days. At the time of the survey, the grievance remained in process, and the facility had not documented a resolution.

During an interview on March 5, 2026, at 12:15 PM, the Surveyor reviewed these findings, including the facility ' s failure to ensure a call bell was accessible for one resident who required staff assistance for basic needs, with the Nursing Home Administrator (NHA) and the Director of Nursing (DON).

28 Pa. Code 201.29 (a) Resident rights.

Plan of Correction - To be completed: 03/17/2026

Resident 1's call bell is within reach of the resident

An initial audit of current resident call bells was completed to ensure that they were within reach of the resident to ensure that they can call for staff assistance when needed.

The ADON/designee has provided education to staff regarding the facilities Policy entitled "Call Lights and Timely Response." DON/designees will conduct Call Bell response audits on all shifts x 3 weekly to ensure that resident call bells are being answered in a timely manner. The NHA/designees will also audit call bell placement on all shifts x 3 weekly to ensure the resident call bell is within reach.

Call bell response audits and call bell placement audits will be conducted on all shifts x 3 weekly x 4 weeks, then 4 times monthly x 3 months. Results of audits will be presented to the resident council monthly for feedback from the residents to ensure satisfaction and to the QAPI committee monthly for further review and recommendations.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(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 the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 5 shifts out of 42 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, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census per the regulation that was effective July 1, 2024.

February 26, 2026- 7.25 nurse aides on the evening shift, versus the required 7.64 for a census of 84.

February 26, 2026- 5.33 nurse aides on the night shift, versus the required 5.60 for a census of 84.

March 1, 2026- 7.47 nurse aides on the day shift, versus the required 8.60 for a census of 86.

March 1, 2026- 4.27 nurse aides on the night shift, versus the required 5.73 for a census of 86.

March 2, 2026- 7.47 nurse aides on the evening shift, versus the required 7.73 for a census of 85.

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

Interview with the Nursing Home Administrator (NHA) on March 5, 2026, at 12:00 PM reviewed the findings of the facility's inability to meet the required nurse aide to resident ratios.

Plan of Correction - To be completed: 03/17/2026

The facility will provide a staffing ratio based on July 1, 2024, regulations of one nurse aide per ten residents on the day shift, one nurse aide per eleven residents during the evening shift, and one nurse aide per fifteen residents during the night shift.

All facility residents have the potential to be affected by this practice.

The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call-off policy to deter unnecessary call-offs. We are also hiring PRN CNAs to assist in covering shifts with call-offs or openings in the schedule. We will be using Indeed for advertisements of open positions, participating in career fairs as they are available. ADON or designee will educate staff on incentives and call off policy.

Administrator/designee during weekday daily review of nursing schedules will audit to ensure Certified Nurse Aide ratios are maintained. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(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.

Plan of Correction - To be completed: 03/17/2026

The facility will provide a staffing ratio of one Licensed Practical Nurse per twenty-five residents on day shift, one Licensed Practical Nurse to thirty residents on evening shift, and one Licensed Practical Nurse per forty residents on overnight shift.

All facility residents have the potential to be affected by this practice.

The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call-off policy to deter unnecessary call-offs. We will be using Indeed for advertisements of open positions, participating in career fairs as they are available, ADON or designee will educate staff on incentives and call off policy.

Administrator/designee during weekday daily review of nursing schedules will audit to ensure that at least required minimum LPN ratios are maintained. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.

§ 211.12(i)(2) LICENSURE Nursing services.:

(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 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 per the regulation effective July 1, 2024:

February 12, 2026- 3.18 direct care nursing hours per resident.

February 26, 2026- 3.15 direct care nursing hours per resident.

March 1, 2026- 2.88 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 Nursing Home Administrator on March 5, 2026, at 12:00 PM reviewed the findings that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 03/17/2026

The facility will provide a minimum of 3.2 hours of direct resident care for each resident.

All facility residents have the potential to be affected by this practice.

The facility has implemented staff incentives for current and new staff as well as reinforcing the facility call-off policy to deter unnecessary call-offs. We will be using Indeed for advertisements of open positions, participating in career fairs as they are available. NHA/DON will educate assigned staff for scheduling to maintain the proper hours of direct resident care per resident.

Administrator/designee during weekday daily review of nursing schedules will audit to ensure a minimum of 3.2 hours of direct resident care for each resident is maintained. The results of these audits will be discussed at the facility QAPI meeting monthly for further review and recommendations.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement