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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF EAST MOUNTAIN
Inspection Results For:

There are 117 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 completed on June 18, 2024, it was determined that Embassy of East Mountain corrected the federal deficiencies cited during the survey of April 12, 2024, under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care but continued to be out of compliance with the requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

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 nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum Nurse Aides (NA) staff to resident ratio was provided on the evening and night shifts for one shifts out of 21 reviewed.

Findings include:

Review of facility census data indicated that on June 13, 2024, the facility census was 103, which required 5.06 NA during night shift. Review of the nursing time schedules revealed 5.02 NA worked the night shift on June 13, 2024.
During an interview on June 18, 2024, at approximately 1:55 PM, the Nursing Home Administrator (NHA) confirmed that the facility failed to provide the minimum nurse aide staffing ratios on the above shift.

Plan of Correction - To be completed: 07/17/2024

The facility cannot retroactively correct the nurse aid ratios.
The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through efforts of retention/recruitment committee

The Scheduler will be re-educated regarding the ratios for nurse aides.

Calculation of the daily nurse aide ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for review and recommendation.

§ 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 that the facility failed to ensure the minimum licensed practical nurse (LPN) staff to resident ratio was provided on the evening, and night shifts for 3 shifts out of 21 reviewed.

Findings include:
Review of facility census data indicated that on June 10, 2024, the facility census was 101, which required 2.53 LPN during night shift. Review of the nursing time schedules revealed 2.47 LPN worked the night shift on June 10, 2024.

Review of facility census data indicated that on June 11, 2024, the facility census was 103, which required 2.58 LPN during night shift. Review of the nursing time schedules revealed 2.25 LPN worked the night shift on June 11, 2024

Review of facility census data indicated that on June 16, 2024, the facility census was 101, which required 2.5 LPN during night shift. Review of the nursing time schedules revealed 2.34 LPN worked the night shift on June 16, 2024.

During an interview on June 18, 2024, at approximately 1:55 PM, the Nursing Home Administrator (NHA) confirmed that the facility failed to provide a minimum licensed practical nurse (LPN) staffing ratios on the above shifts.

Plan of Correction - To be completed: 07/17/2024

The facility cannot retroactively correct the LPN ratios.
The facility is focusing on retention of existing LPNs through efforts of retention / recruitment committee.

The Scheduler will be re-educated regarding the ratios for LPN's .

Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler /designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for review and recommendations

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