F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and staff interview it was determined that the facility failed to provide housekeeping and
maintenance services to maintain a clean, safe, and functional environment on two of two resident units
currently in use (Blue and [NAME] Units).
Findings include:
At time of survey ending April 21, 2023, only two of three available resident units were being utilized by the
facility to house residents.
Observations during an environmental tour of the facility on April 18, 2023, at approximately 9:30 AM, in the
resident dining room located on Blue Wing, revealed broken base board molding along the left wall, and
brown stains on ceiling along the ceiling vent and two large holes in the wall between the residents' beds.
Observation of the hallway between [NAME] Wing and Blue Wing revealed large holes/openings in the wall
along the baseboard molding.
Observation of room [ROOM NUMBER], which was occupied by two residents, revealed baseboard
molding to the right of the heating/cooling unit was pulled away from the wall exposing broken/crumbling
drywall.
The baseboard molding to the left of the heating/ac unit was pulled away from the wall, exposing damaged
drywall. The baseboard molding which was adhered to the wall was heavily soiled with dark brown/black
grime.
The ceiling tiles above the resident's bed located by the window were stained brown and the ceiling tile by
the window appeared to have been painted/ repaired with tan/beige paint.
The floor of the entrance into the resident's bathroom was heavily stained with thick black substance and
the door leading into the adjoining room had many areas of missing/chipping paint along the bottom of the
door and on each door frame. Small brown stains were observed on the privacy curtain for the resident
located by the door.
Observation of room [ROOM NUMBER], which was occupied by two residents, revealed broken baseboard
molding to the left of the heating/ac unit, and a cable box system (which was no longer in use by the facility)
laying on the floor. The baseboard molding behind and to the right of the resident's bed
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
395433
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395433
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/21/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Tunkhannock
30 Virginia Drive
Tunkhannock, PA 18657
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
located by the window was pulled away from the wall in two separate areas and the exposed wall was
black/dark brown in color. The ceiling tiles above the window were heavily stained and discolored. The wall
between the resident bathroom and closet had a large area of missing paint.
Observation of the Blue Wing resident care unit revealed that the door to enter the resident shower room
was missing large areas of paint. The resident shower stall area revealed dark discolored tiles along the
edges entering the stall, and along the edges and corners once in the shower stall. The toilet used for
residents was missing the top to the tank. A piece of plastic was on top of the tank.
Further observation of the Blue Wing resident care unit revealed a broken ceiling tile with vent and brown
stained ceiling tile outside the shower room in the hallway. Multiple brown stained ceiling tiles were
observed in the hallway from the nurse's station to the last resident room. The ceiling tiles beside the air
vents were heavily soiled with dark colored dust and the vents were coated with a thick brown film. Broken,
missing, and cracked floor tiles were observed in the middle of the same hallway where a gold-colored
metal plates were located. Torn drywall was observed at numerous hand sanitizer stations outside resident
rooms. In the hallway beside the resident pantry room, a large, exposed hole was observed in the wall.
Observation of the [NAME] Wing resident care unit revealed the area between the nurse's station and the
resident hallway was heavily soiled with a thick gummy substance, and the wall entering the same hallway
was missing drywall. The ceiling above the [NAME] Wing medication room was heavily stained. The door to
enter the resident shower room was missing large areas of paint and heavily soiled with black along the
bottom of the door. The toilet in the resident shower did not have a cover on the tank.
Observation of room [ROOM NUMBER] which was occupied by two residents, revealed cracked and
peeling drywall to the right of the heating/ac unit.
Observation of room [ROOM NUMBER] which was occupied by two residents, revealed a heavily damaged
wall next to the resident bathroom entrance. The baseboard molding was pulled away from the wall,
exposing damaged drywall. The wall above the same molding was missing paint and in need of repair. The
bathroom floor was stained black and had long linear cracks the length of the wall.
Observation of room [ROOM NUMBER] which was not occupied by residents at the time of the
observation, revealed the baseboard molding pulled away from the wall that was next to the bathroom.
Behind the baseboard molding was crumbling and discolored drywall, and the wall was heavily damaged.
The bathroom floor was discolored/stained black, and a high-rise toilet seat attachment was on the floor
next to the toilet. The seat was in a clear bag which was stained with a rust-colored material on the inside of
the bag. The floor edging behind the toilet was pulled away from the wall.
Observations of both the Blue and [NAME] Wing resident care units were confirmed by the Nursing Home
Administrator (NHA) on April 19, 2023, at approximately 11 AM. Interview with the NHA during additional
environmental tour of the facility revealed that the heating/ac unit in room [ROOM NUMBER] was not in
proper operating condition and needed repair. The NHA further stated that the room had been occupied,
but the residents were moved due to the condition of the room.
Interview with the Nursing Home Administrator (NHA), on April 19, 2023, at approximately 12 PM,
confirmed that the resident environment was to be maintained in a safe, clean and functional manner.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395433
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395433
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/21/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Tunkhannock
30 Virginia Drive
Tunkhannock, PA 18657
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
28 Pa Code 207.2(a) Administrator's responsibility
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395433
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395433
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/21/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Tunkhannock
30 Virginia Drive
Tunkhannock, PA 18657
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of the facility's 4-week menu cycle and resident and staff interviews, it was determined that the
facility failed to serve a varied menu with reasonable efforts to meet individual resident food preferences for
menu variety.
Findings included:
During a group meeting conducted on April 19, 2023, at 10:01 AM, with Residents 23, 27, 33, 34, and 37,
revealed that the residents in attendance voiced concerns that the facility's menu lacked variety and similar
foods were served repeatedly, at consecutive meals.
Review of the facility's Fall/Winter 2022-2023 menu revealed that was implemented by the facility on
November 6, 2022, and continued through survey ending April 21, 2023 revealed that during week 1, on
Tuesday the planned entrée for dinner was chicken tenders and then for lunch on Wednesday, the
planned lunch was chicken [NAME] over noodles. Chicken would be served for consecutive meals. The
planned entrée for dinner on Wednesday was a hamburger, and then the planned entrée for
Thursday lunch would be beef vegetable stew. Beef would be served for consecutive meals. The planned
entrée for Friday dinner would be chicken cacciatore over noodles, and then the main entrée
for Saturday lunch would be turkey pasta [NAME]. Additionally, the planned lunch entrée for Sunday
week 2 was Italian baked chicken and the planned entrée for dinner was vegetable lasagna (pasta).
Poultry and pasta were served for consecutive meals/days during week 1 and into week 2.
Review of the facility's 4-week menu cycle Fall/Winter Menu: week 2, revealed that on Mondays the planned
entrée for lunch would be meatloaf and the planned dinner entrée would be a stuffed green
pepper (beef). The planned entrée for Saturday dinner would be chicken tenders and then on
Sunday week 3 lunch the planned meal would be turkey with cranberry glaze (poultry), and then the
planned lunch entrée week 3 Monday would be chicken vegetable stew. Poultry was served to the
residents for consecutive meals/days during week 2 and into week 3.
The Fall/Winter menu during week 3, revealed that the main entrée served for Monday dinner would
be tuna noodle casserole, and then the planned main entrée for Tuesday lunch would be corn flake
fish. Fish was served to the residents for consecutive meals. The main entrée served Week 3
Saturday would be meatloaf (beef) and then the planned entrée Week 4 Sunday lunch would be
roast beef. Beef was served to the residents for consecutive meals during week 3 and into week 3.
During week 4 of the Fall/Winter menu the main entrée served for Tuesday dinner would be a
hamburger and then the planned main entrée for Wednesday lunch would be Salisbury steak (beef),
and then the planned entrée for Thursday dinner would be lasagna with meat sauce.
Beef was served to the residents for consecutive meals/days during week 4.
Interview with the facility's Certified Dietary Manager (CDM) on April 20, 2023, at 11:30 AM, revealed that
the menus were planned by the corporate Registered Dietitian (RD). The CDM acknowledged that the
residents had concerns that the current menu was repetitive and did not offer enough variety.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395433
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395433
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/21/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Embassy of Tunkhannock
30 Virginia Drive
Tunkhannock, PA 18657
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
28 Pa. Code 211.6(c) Dietary services.
Level of Harm - Minimal harm
or potential for actual harm
28 Pa. Code 201.29(a)(i)(j) Resident rights.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395433
If continuation sheet
Page 5 of 5
