Pennsylvania Department of Health
EMBASSY OF SCRANTON
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF SCRANTON
Inspection Results For:

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EMBASSY OF SCRANTON - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on May 29, 2024, it was determined that there were no federal deficiencies cited under the requirements of 42 CFR Part 483 Subpart B as they relate to the health portion of the survey process, but The Gardens at Scranton was not in compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regualtions.

Plan of Correction:

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing time schedules and the resident census and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff on 5 shifts out of 21 reviewed (May 17-23, 2024).

Findings include:

A review of the facility's weekly staffing records May 17-23, 2024, revealed that on the following dates the facility failed to provide a minimum one nurse aide per 12 residents on the day and evening shift and one nurse aide per 20 on the night shift based on the facility's census.

Review of facility census data indicated that on May 17, 2024, the facility census was 73, which required 6.08 nurse aides during the day shift. Review of the nursing time schedules revealed 6.0 nurse aides worked the day shift on May 17, 2024.

Review of facility census data indicated that on May 17, 2024, the facility census was 73, which required 6.08 nurse aides during the evening shift. Review of the nursing time schedules revealed 6.0 nurse aides worked the evening shift on May 17, 2024.

Review of facility census data indicated that on May 18, 2024, the facility census was 73, which required 6.08 nurse aides during the evening shift. Review of the nursing time schedules revealed 3.0 nurse aides worked the evening shift on May 18, 2024.

Review of facility census data indicated that on May 20, 2024, the facility census was 72, which required 6.0 nurse aides during the day shift. Review of the nursing time schedules revealed 5.0 nurse aides worked the day shift on May 20, 2024.

Review of facility census data indicated that on May 21, 2024, the facility census was 72, which required 6.0 nurse aides during the evening shift. Review of the nursing time schedules revealed 4.0 nurse aides worked the evening shift on May 21, 2024.

Review of facility census data indicated that on May 22, 2024, the facility census was 72, which required 6.0 nurse aides during the evening shift. Review of the nursing time schedules revealed 5.0 nurse aides worked the evening shift on May 22, 2024.

During an interview on May 29, 2024, at 1:00 PM the Nursing Home Administrator confirmed that the facility failed to provide a minimum nurse aide staffing ratios on the above shifts.

Plan of Correction - To be completed: 07/29/2024

1. The facility cannot retroactively correct the cited days/shifts regarding facility not meeting CNA requirements.
2. The facility will continue to staff per required CNA ratios.
3. Staffing to continue to be reviewed daily by NHA or designee as well as census management.
4. Incentives to be reviewed to recruit additional nursing staff.
5. Audits to be submitted to QAPI for 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: 07/29/2024

1. The facility cannot retroactively correct the cited days/shifts regarding facility not meeting LPN requirements.
2. The facility will continue to staff per required LPN ratios.
3. Staffing to continue to be reviewed daily by NHA or designee as well as census management.
4. Incentives to be reviewed to recruit additional nursing staff.
5. Audits to be submitted to QAPI for review and recommendations

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined the facility failed to ensure a minimum of one Registered Nurse (RN) staff to resident ratio was provided on the days, and night shift for one shift out of 21 reviewed.

Findings include:

A review of the facility's weekly staffing records May 17-23, 2024, revealed that on the following dates the facility failed to provide minimum Registered Nurse (RN) staff of 1:250 on the night shift based on the facility's census.

Review of nursing staff care hours provided by the facility revealed the facility resident census of 73 for night shift on May 18, 2024, which required 1.00 RN during night shift. Review of the nursing time schedules revealed 0.50 RN worked the night shift on May 18, 2024.

During an interview on May 29, 2024, at approximately 12:55 PM, the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum Registered Nurse (RN) staffing ratios on the above shifts.

Plan of Correction - To be completed: 07/29/2024

1. The facility cannot retroactively correct the cited shift without consecutive RN coverage.
2. The facility will continue to staff per the required RN charge nurse ratios.
3. Staffing will continue to be reviewed daily by NHA or designee. The facility is focusing on retaining current nursing staff and recruiting new nursing staff via recruitment team. Also, the facility is implementing staff incentives for current and new staff as well as reinforcing call off policy to deter unnecessary call outs. NHA or designee will educate staff on incentives and call off policy.
4. Audits to be submitted to QAPI for review and recommendations.

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.

Observations:

Based on review of facility nurse staffing data, it was determined that the facility failed to maintain a minimum of 2.87 hours of direct resident care for each resident.

Findings include:

A review of facility nurse staffing data, including deployment sheets for the week of May 17-23, 2024, the facility's 24 hour daily nurse staffing nurse staffing was below 2.87 hrs per resident on the following days:

May 17, 2024 nursing hours of direct resident care for each resident was 2.85
May 18, 2024 nursing hours of direct resident care for each resident was 2.47

During an interview on May 29, 2024, at approximately 12:55 PM, the Nursing Home Administrator (NHA) confirmed the nursing hours indicated above.

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