Pennsylvania Department of Health
EMBASSY OF WYOMING VALLEY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMBASSY OF WYOMING VALLEY
Inspection Results For:

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

Initial comments:

Based on a revisit and abbreviated complaint survey completed on June 27, 2024, it was determined that Embassy of Wyoming Valley failed to correct federal deficiencies cited during the survey of April 26, 2024, and continued to be out of compliance with the following requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean and safe resident environment.

Findings include:

Observations on June 27, 2024, at approximately 8:55 AM of the second floor resident unit revealed the following:

Dirt and debris was observed on the floors throughout the hallway.

Floor molding was observed peeling off the wall in the hallway.

A piece of the vinyl flooring was missing in the hall.

Observation in the small resident dining room revealed dirt, debris and food particles on the floor. The floor was sticky next to the supply cabinet. Multiple dried brown spots were observed on the cabinet next to the refrigerator.

Observation in resident Room 214 revealed large gouges in the wall. Food particles were observed on the floor. Spots of brown substance were observed on the closet doors. Observation in the bathroom of this resident room, revealed brown spots on the bathroom wall.

Observation in resident Room 226 revealed black streaks on the wall by the bathroom door and the plaster was chipped and crumbling. Brown smudges and spots were observed on the bathroom wall. There was a strong smell of feces lingering in the bathroom.

Observation in resident Room 206 revealed dirt, debris, and food particles on the floor. A brown substance had dripped down the wall next to the bathroom door. There were dried brown spots observed on the closet doors and floor.

A brown fecal like substance was observed on the toilet seat in the spa room. A black mold like substance was observed on the shower curtains. Dirt and debris were observed on the floor. The door to the spa room did not function properly whereas the door to the room would not completely close. Used tissues were observed on the floor in the private bath. There was a dried black substance adhered to the bathroom floor. There was brown fecal like spots on the toilet seat. There were tears in the shower curtain.

An observation on June 27, 2024, at approximately 9:25 AM of the third floor resident unit revealed the following:

Observation in resident Room 330 revealed gouge out of the surface of the wall. The floor was sticky. Food, dirt, and debris was observed on the floor of the resident room and bathroom. A a broken floor tile was observed near the toilet. The toilet paper holder was broken.

Observation in resident Room 310 revealed a dried sticky substance on the floors. Brown spots were observed on the closet doors. The sheet rock wall was damaged. There were large cracks and indents in the wall. Multiple holes were observed in the wall, next to the bed. There were brown and red spots and dried drips on the surface of the walls. A hole was observed in the bathroom door.

Dirt and debris was observed on the floor of the hallway.

Dirt, debris and food particles were observed on the floor of the small dining area.

Observation in the spa room, revealed that the shower curtain was ripped and coated with a black mold-like substance. A cracked floor tile was observed near the shower. The toilet paper holder was broken in the private bath. Brown fecal like smears were observed on the wall next to the sink. The shower curtain in the private bath presented a black-mold like substance.

Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on June 27, 2024, at approximately 2:15 PM confirmed that the facility is to be maintained daily to provide a clean and sanitary environment for the residents.

28 Pa. Code 201.18 (e)(2.1) Management

Plan of Correction - To be completed: 07/26/2024

The second-floor hallway floors have been cleaned. The second-floor dining room floor and supply cabinets have been cleaned and sanitized. Rooms 206 and 226 have been cleaned and the plaster on the wall has been fixed. The spa room on the 2nd and 3rd floor has been cleaned, sanitized and repairs made. The door to the spa room has been adjusted. The private bathrooms on the 2nd and 3rd floors have been cleaned and sanitized. Rooms 310 and 330 have been cleaned and repairs completed.

No other areas were affected.

The housekeeping director/designee will in-service the housekeeping staff regarding thorough cleaning of spa bathrooms, resident bathrooms and common areas.

The housekeeping director/designee will audit 5 random rooms on the 2nd floor, 5 random rooms on the 3rd floor, 2 common areas on 2nd and 3rd floor 1x/day for 60 days to insure a clean and sanitary environment.

The results of the audit will be presented to the QA committee for review and recommendations.

§ 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 aide staff to resident ratio was provided on each shift for two shifts out of 44 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 1:12 on the evening shift and 1:20 on the night shift based on the facility's census.

June 15, 2024 - 4.88 nurse aides on the evening shift, versus the required 6.92 for a census of 83.

June 21, 2024 - 2.83 nurse aides on the night shift, versus the required 4.05 for a census of 81.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on June 27, 2024, at approximately 2:15 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.

Plan of Correction - To be completed: 07/26/2024

Facility cannot retroactively correct this deficiency.

Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff will be utilized for open shifts if available.

Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff.

The Director of Nursing/designee will review the ratio daily for compliance.
All efforts will be made to meet certified aide staffing ratios. If a call off occurs all efforts will be made to fill that position.

The Director of Nursing/designee will audit the certified aide ratio 1x/week for 4 weeks then monthly for 2 months.

Results of the audits will be presented to the QA committee 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 staff to resident ratio was provided on each shift on four shifts out of 44 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 1:30 on the evening shift and 1:40 on the night shift based on the facility's census.

June 16, 2024 - 1.13 LPNs on the night shift, versus the required 2.08 for a census of 83.
June 23, 2024 - 2.05 LPNs on the evening shift, versus the required 2.70 for a census of 81.
June 23, 2024 - 1.10 LPNs on the night shift, versus the required 2.03 for a census of 81.
June 24, 2024 - 1.60 LPNs on the night shift, versus the required 2.03 for a census of 81.

On the above dates mentioned no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on June 27, 2024, approximately 2:15 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.

Plan of Correction - To be completed: 07/26/2024

Facility cannot retroactively correct this deficiency.

Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff will be utilized for open shifts if available.

Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all new nursing staff.

The Director of Nursing/designee will review the ratio daily for compliance.
All efforts will be made to meet LPN staffing ratios. If a call off occurs all efforts will be made to fill that position.

The Director of Nursing/designee will audit the LPN ratio 1x/week for 4 weeks then monthly for 2 months.

Results of the audits will be presented to the QA committee for review and recommendation.

§ 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 and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily.

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 2.87 hours of general nursing care to each resident:

June 15, 2024 -2.67 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 Nursing Home Administrator on June 27, 2024, at approximately 2:15 PM confirmed the facility failed to consistently provide minimum general nursing care hours to each resident daily.

Plan of Correction - To be completed: 07/26/2024

The Facility cannot retroactively correct this deficiency.

Recruitment of nursing staff will continue via facility websites, Indeed, social media websites, job fairs, off site recruiters and instant interviews from walk-in candidates. Agency staff will be utilized for open shifts if available.

Retention efforts will be made in earnest. Referral bonuses are offered to current employees. The facility is currently offering a significant sign-on bonus for all nursing staff.

The Director of Nursing/designee will review the PPD daily for compliance. All efforts will be made to meet the required PPD of 2.87. If a call off occurs all efforts will be made to achieve the PPD.

The Director of Nursing/designee will audit the PPD 1x/week for 4 weeks then monthly for 2 months.

Results of the audit will be presented to the QA committee for review and recommendation.

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