Pennsylvania Department of Health
EMBASSY OF EAST MOUNTAIN
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 EAST MOUNTAIN
Inspection Results For:

There are 130 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 a revisit survey completed on March 3, 2026, it was determined that Embassy of East Mountain corrected the federal deficiencies cited during the survey of January 9, 2026, under the requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities however the facility continued to be out of compliance with the following requirements of 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 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 4 shifts out of 21 shifts 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.

February 23, 2026 8.0 nurse aides on the day shift, versus the required 10.0 for a census of 100.
February 24, 2026 5.0 nurse aides on the night shift, versus the required 6.67 for a census of 100.
February 26, 2026 8.06 nurse aides on the evening shift, versus the required 9.18 for a census of 101.
February 26, 2026 6.0 nurse aides on the night shift, versus the required 6.73 for a census of 101.

No additional excess higher level of staff was available to compensate for this deficiency.

An interview with the Director of Nursing on March 3, 2026, at 1:00 PM confirmed the facility had not met the required nurse aide to resident ratios on the above dates.

Plan of Correction - To be completed: 04/07/2026

1. The facility cannot retroactively correct the nurse aide ratios.
2. The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through efforts of the Human Resource Department and the management team.
3. The Scheduler and Nursing Supervisors will be re-educated by NHA/Designee regarding the ratio requirements for nurse aides. Daily staffing meetings will review calculations of the nurse aide ratios for accuracy.
4. Daily ratios will be quality monitored weekly for 4 weeks and monthly for 2 months. Findings will be submitted to the QAPI committee for further 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.

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 for one shift out of 21 shifts reviewed.

Findings include:

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

February 26, 2026 2.28 LPNs on the night shift, versus the required 2.53 for a census of 101.

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

An interview with the Director of Nursing on March 3, 2026, at 1:00 PM confirmed the facility did not meet the required LPN to resident ratio on the above date.

Plan of Correction - To be completed: 04/07/2026

1. The facility cannot retroactively correct the LPN ratios.
2. The facility is focusing on retention of existing LPNs and recruitment of new LPNs through efforts of the Human Resource Department and the management team.
3. The Scheduler and Nursing Supervisors will be re-educated by the NHA/Designee regarding the ratio requirements for LPNs. Daily staffing meetings will review calculations of the LPN ratios for accuracy.
4. Daily ratios will be quality monitored weekly for 4 weeks and monthly for 2 months. Findings will be submitted to the QAPI committee for further 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 on three days out of seven 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:

February 23, 2026 3.11 direct care nursing hours per resident.
February 24, 2026 3.13 direct care nursing hours per resident.
February 26, 2026 3.04 direct care nursing hours per resident.

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

An interview with the administrator on March 3, 2026, at 1:00 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 04/07/2026

1. The facility cannot retroactively correct the total number of hours of general nursing care provided on identified days.
2. The facility is focusing on retention of existing staff and recruitment of new hires through efforts of the Human Resource Department and the management team.
3. The Scheduler and Nursing Supervisors will be re-educated by the NHA/Designee regarding the total number of general nursing care hours required. Daily staffing meetings will review calculations of hours for accuracy.
4. Daily general nursing care hours will be quality monitored weekly for 4 weeks and monthly for 2 months. Findings will be submitted to the QAPI committee for further 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