Pennsylvania Department of Health
EMBASSY OF TUNKHANNOCK
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF TUNKHANNOCK
Inspection Results For:

There are 111 surveys for this facility. Please select a date to view the survey results.

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

Initial comments:
Based on a revisit survey completed on August 12, 2024, it was determined that The Embassy of Tunkhannock failed to correct the deficiencies cited during the survey of May 21, 2024, and 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:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

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.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on a review of clinical records and select investigation reports and staff interviews, it was determined the facility failed to provide timely supervision, and effective safety measures for a resident with known unsafe behaviors and unwitnessed falls, to prevent a fall with injury, for one resident out of 9 sampled residents (Resident 1).

Findings include:

Clinical record review revealed that Resident 1 was admitted to the facility on May 20, 2024, with diagnoses of dementia, and history of repeated falls.

An admission MDS (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 27, 2024, revealed that the resident was severely cognitively impaired with a BIMS score of 0 (a score of 0 to 7 indicates severe cognitive impairment). The resident required complete staff assistance with transfers from chair to bed and toileting and required substantial/maximal staff assistance bed mobility, sit to stand and activities of daily living.

A review of a current care plan initiated May 22, 2024, for at risk for falls related to decline in functional status, with the goal that resident will remain free from falls/injury through next review. Interventions included anti roll backs to wheel chair, assist of one staff member for transfers, bed alarm to alert staff of unsafe movement, resident will not to be left unattended in bathroom, fall mat to bilateral bedside, keep call bell within reach and encourage use, answer promptly, keep environment clutter free, keep room well lighted, keep bed in lowest position, offer the resident the choice to go to bed after dinner, make sure resident is wearing proper footwear, use of a chair seating equipment as ordered, encourage frequent rest periods, and wheelchair alarm.

A review of nursing documentation dated July 24, 2024, at 2:18 AM revealed the resident was " up all night with multiple attempts to self-rise " . According to the documentation, redirection was not effective. The resident was sitting in her wheelchair in front of the nurse ' s station, snacks were offered and accepted, and the note indicated the safety measures were in place.

A review of nursing documentation dated July 26, 2024, at 2:00 AM revealed that Resident 1 continues to transfer herself in and out of her bed. The note further indicated she unclipped the chair alarm which notified staff of her unsafe movements. The clip alarm was relocated out of the resident's reach to ensure proper functioning. After the failure to redirect the resident she was transported to the nursing station or increased supervision.

Resident 1 was being monitored every 15 minutes to ensure her safety. Documentation indicted she was last observed at 3:50 AM with non-skid footwear, and clip alarm to her wheelchair.

A review of a facility investigative report dated July 26, 2024, at 4:00 AM revealed that Resident 1 attempted to self-ambulate from her wheelchair in the main lobby sustaining a fall. There was no evidence of injury at the time of the fall.

Documentation dated July 26, 2024, at 8:58 AM indicated that Resident 1 had complaints of right leg pain and was resting in bed. An X-ray was completed of her right hip and right femur (leg) and x-ray results dated July 26, 2024, at 8:59 AM revealed that Resident 1 had sustained mildly displaced and comminuted acute pelvic fractures of the right inferior and superior pubic rami (bones that make up the pelvis).

Documentation dated July 26, 2024, at 10:06 AM revealed that orders were obtained from the physician to send Resident 1 to the emergency room for evaluation. Resident 1 was sent to the emergency room at 10:35 AM and returned to the facility at 5:04 PM.

Review of hospital evaluation confirmed that Resident 1 had sustained a " closed fracture of right inferior pubic ramus and returned to the facility with orders to follow-up with orthopedics in 4-6 weeks with repeat x-rays, and a prescription for narcotic pain medication.

Documentation dated July 26, 2024, at 5:19 AM indicated that interventions implemented upon resident return from the emergency room included every 15-minute monitoring and pain management.

The facility failed to demonstrate the provision of effective interventions to prevent resident fall with injury.

Interview with the Director of Nursing on August 12, 2024, at 2:30 P.M confirmed that despite frequent supervision, the facility was unable to prevent Resident 1's fall with injury.

28 Pa Code 211.12 (d)(3)(5) Nursing services

Plan of Correction - To be completed: 09/05/2024

The facility cannot retroactively correct the citation for not providing resident with an effective intervention to prevent a fall with injury. Facility will provide 1:1 supervision until resident behaviors subside to prevent a fall with injury.

The facility will conduct fall risk assessments on all residents to identify those at risk, care plans will be updated to reflect increased supervision when required and triggers for behaviors if any.

Education will be provided to nursing staff regarding effective interventions to prevent a fall with injury.

DON will review all fall related incidents to ensure effective interventions were put into place and utilized during daily clinical meetings weekly X 4 weeks, then monthly x 2 months. Results will be sent to the QA Committee for review and to ensure adequate interventions and follow up is completed.

§ 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.

Plan of Correction - To be completed: 09/05/2024

Facility cannot retroactively correct past CNA to resident ratios.

2. Facility is focusing on retention of existing nursing assistants and recruitment of new nursing assistants, through efforts of the Human Resources Manager and Nursing Administration. A third-party recruitment agency has been contracted to assist with candidates. Nursing assistant rates have been increased per new union contract with Embassy Healthcare, LLC.

3. The scheduler has been re-educated regarding the CNA ratio regulatory requirements. Calculation of the daily CNA ratios will be completed and reviewed for accuracy by the scheduler/designee. Facility acquired OnShift applications for scheduling. Application alerts scheduler, DON, and Administrator when nursing ratios are not scheduled to be met so that corrections, additions etc. can be made to meet minimum requirements.

4. Daily ratios will be audited weekly X 4 weeks then monthly X 2 months. Audits will be reviewed at QAPI for compliance.

§ 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 schedules, and staff interview, it was determined the facility failed to provide one licensed practical nurse per 25 residents on the day shift, one LPN per 30 residents on the evening shift, and one LPN per 40 residents on the night shift on 6 of the 14 days and 9 of the 42 shifts reviewed. (July 20, 2024, July 22, 2024, July 25, 2024, August 5, 2024, August 9, 2024 and August 10, 2024).

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 to resident ratio based on the facility's census.

July 20, 2024 - 2 LPNs on the evening shift, versus the required 2.5 for a census of 72

July 20, 2024 - 1 LPNs on the night shift, versus the required 2 for a census of 72

July 22, 2024 - 2.5 LPNs on the evening shift, versus the required 3 for a census of 71

July 25, 2024 - 1 LPN on the night shift, versus the required 2 for a census of 71

August 5, 2024 - 2 LPNs on the day shift, versus the required 3 for a census of 73

August 5, 2024 - 1 LPN on the night shift, versus the required 2 for a census of 73

August 9, 2024 - 2 LPNs on the evening shift, versus the required 2.5 for a census of 73

August 9, 2024 - 1 LPN on the night shift, versus the required 2 for a census of 73

August 10, 2024 - 1 LPN on the night shift, versus the required 2 for a census of 73

No additional excess higher-level staff were available to compensate this deficiency on the above dates and shifts.

The facility did not met the required LPN to resident ratios on all three shifts during the above dates.

Plan of Correction - To be completed: 09/05/2024

Facility cannot retroactively correct past LPN to resident ratios.

2. Facility is focusing on retention of existing LPNs and recruitment of new LPNs, through efforts of the Human Resources Manager and Nursing Administration. A third-party recruitment agency has been contracted to assist with candidates. LPN rates have been increased per new union contract with Embassy Healthcare, LLC.

3. The scheduler has been re-educated regarding the LPN ratio regulatory requirements. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee.

4. Daily ratios will be audited weekly X 4 weeks then monthly X 3 months. Audits will be reviewed at QAPI for compliance.

§ 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 a review of nurse staffing schedules 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:

Review of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, Nursing Services, dated July 1, 2023, indicated the following subsections.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period as follows:
(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.

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident per the regulation effective July 1, 2023:

July 20, 2024 - 2.76 nursing hours per resident per 24 hours.

The facility's general nursing hours were below minimum required levels of 2.87 hours of direct nursing care daily for each resident on the dates noted above.

Plan of Correction - To be completed: 09/05/2024

Facility cannot retroactively correct past nursing hours.

2. Facility is focusing on retaining current nursing staff and recruitment using in-house recruitment resources and a third-party recruitment firm dedicated to only nursing applicants to correct nursing hours.

3. Facility is implementing staff incentives for current and new staff as well as reinforcing the facility call off policy to deter unnecessary call offs. NHA or designee will educate staff on incentives and call off policy.

4. NHA/designee will audit nursing hours weekly for three weeks then monthly X 3 months. Audits will be reviewed by QA monthly X 3 months to ensure compliance with POC.

§ 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.

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