Pennsylvania Department of Health
 EMBASSY OF EAST MOUNTAIN
Patient Care Inspection Results

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EMBASSY OF EAST MOUNTAIN
Inspection Results For:

There are  122 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 EAST MOUNTAIN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint and Revisit Survey, completed on May 29, 2025, it was determined Embassy of East Mountain corrected the federal deficiencies cited during the survey of March 7, 2025, but 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(f)(10)(iv)(v) REQUIREMENT Notice and Conveyance of Personal Funds: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(f)(10)(iv) Notice of certain balances.
The facility must notify each resident that receives Medicaid benefits-
(A) When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and
(B) That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

§483.10(f)(10)(v) Conveyance upon discharge, eviction, or death.
Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.
Observations:

Based on a review of clinical records and residents' financial account records and staff interview, it was determined the facility failed to return the personal funds of one discharged resident (Resident CR1) within 30 days of discharge, for one of 12 residents reviewed.

Findings include:

Clinical record review revealed that Resident CR1 was admitted to the facility on November 12, 2024, and discharged on January 2, 2025.

A review of the resident's financial account statement, provided by the facility and dated June 1, 2025, revealed a credit balance of $12,743.00 remained on the account, indicating funds belonging to Resident CR1 had not been disbursed within 30 days of the resident's discharge.

Further review included an email, provided to the surveyor, from the Regional Business Office Manager (RBOM) dated May 29, 2025, which stated the facility's Business Office Manager was terminated on March 4, 2025, due to poor performance. The RBOM subsequently assumed responsibility for financial operations at this facility and two others. The RBOM acknowledged that the resident's refund had not been processed in a timely manner and that the refund was now scheduled to be issued on June 5, 2025.

During an interview with the Director of Nursing on May 29, 2025, at 10:45 AM, it was confirmed that Resident CR1's personal funds were not returned within the required 30-day period following discharge from the facility.

28 Pa. Code: 201.18 (b)(2)(e)(1) Management.

28 Pa. Code 201.29(a) Resident rights



 Plan of Correction - To be completed: 06/05/2025

The check for the delayed payment has been processed and the check will be issued and mailed on 6/5/25.
The Regional Business Office Manager, working with corporate business office staff reviewed refunds past and pending for timeliness.
No other refunds were found or projected to be late.
Our oncoming Business Office Manager will be educated on timeliness of refunds due to residents after discharge.
To ensure ongoing compliance, the regional Business Office Manager will also provide monitoring of timely refund payments weekly for 4 weeks then monthly for 2 months.
All results will be discussed at the facilities QAPI meetings.

§ 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 the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 7 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, 1:11 on the evening shift, and 1:15 on the night shift based on the facility's census.

April 28, 2025, 8.56 NAs on the day shift, versus the required 9.6, for a census of 96
April 28, 2025, 6 NAs on the night shift, versus the required 6.4, for a census of 96
May 1, 2025, 8.53 NAs on the evening shift, versus the required 8.91, for a census of 98
May 1, 2025, 5.06 NAs on the night shift, versus the required 6.53, for a census of 98
May 2, 2025, 5.97 NAs on the night shift, versus the required 6.47, for a census of 97
May 3, 2025, 8.25 NAs on the evening shift, versus the required 8.91, for a census of 98
May 3, 2025, 5.56 NAs on the night shift, versus the required 6.53, for a census of 98

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 28, 2025, at approximately 1:30 p.m., confirmed the facility had not met the required NA to resident ratios on the above dates.



 Plan of Correction - To be completed: 06/05/2025

The facility cannot retrospectively correct staffing hours.
The facility scheduler staffs each day with adequate staff to meet the individual and overall staffing requirements. In the event of call offs, the facility has engaged additional staffing agencies to be used to supplement hours in RN, LPN and C.N.A. as well as overall staffing.
The facility now offers additional shift pick up incentives to staff not only for full, but also partial shift pick up. The Administrator / designee will provide updated education to direct care staff on shift pick up incentives.
The facility is holding a major /targeted recruitment effort in June 2025 with increased hiring incentives for sign on and referral of staff.
The facility now also has the ability to reach out to a nearby sister facility for additional staff, as needed, to meet staffing requirements.
The facility adHOC QAPI committee will review staffing levels daily during stand up meetings and report to the facility QAPI committee quarterly and more often as needed.

§ 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 ratio to resident ratio was provided on each shift for 3 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 1:25 on the day shift, 1:30 on the evening shift, and 1:40 on the night shift based on the facility's census.

April 28, 2025, 2.16 LPNs on the night shift, versus the required 2.4, for a census of 96
April 29, 2025, 2.19 LPNs on the night shift, versus the required 2.42, for a census of 97
May 3, 2025, 3.09 LPNs on the evening shift, versus the required 3.27, for a census of 98

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 29, 2025, at approximately 1:00 p.m., confirmed the facility had not met the required LPN to resident ratios on the above dates.



 Plan of Correction - To be completed: 06/05/2025

The facility cannot retrospectively correct staffing hours.
The facility scheduler staffs each day with adequate staff to meet the individual and overall staffing requirements. In the event of call offs, the facility has engaged additional staffing agencies to be used to supplement hours in RN, LPN and C.N.A. as well as overall staffing.
The facility now offers additional shift pick up incentives to staff not only for full, but also partial shift pick up. The Administrator / designee will provide updated education to direct care staff on shift pick up incentives.
The facility is holding a major /targeted recruitment effort in June 2025 with increased hiring incentives for sign on and referral of staff.
The facility now also has the ability to reach out to a nearby sister facility for additional staff, as needed, to meet staffing requirements.
The facility adHOC QAPI committee will review staffing levels daily during stand up meetings and report to the facility QAPI committee quarterly and more often as needed.

§ 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 the facility failed to consistently provide minimum general nursing care hours to each resident daily on 2 out of the 21 days reviewed.

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:

April 28, 2025 - 3.07 direct care nursing hours per resident.
May 3, 2025 - 3.14 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 29, 2025, at approximately 1:00 p.m., confirmed that the facility failed to consistently provide minimum general nursing care hours to each resident daily.



 Plan of Correction - To be completed: 06/05/2025

The facility cannot retrospectively correct staffing hours.
The facility scheduler staffs each day with adequate staff to meet the individual and overall staffing requirements. In the event of call offs, the facility has engaged additional staffing agencies to be used to supplement hours in RN, LPN and C.N.A. as well as overall staffing.
The facility now offers additional shift pick up incentives to staff not only for full, but also partial shift pick up. The Administrator / designee will provide updated education to direct care staff on shift pick up incentives.
The facility is holding a major /targeted recruitment effort in June 2025 with increased hiring incentives for sign on and referral of staff.
The facility now also has the ability to reach out to a nearby sister facility for additional staff, as needed, to meet staffing requirements.
The facility adHOC QAPI committee will review staffing levels daily during stand up meetings and report to the facility QAPI committee quarterly and more often as needed.


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