Health inspection·January 22, 2024

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a review of select facility policy and grievances lodged with the facility and and interviews with the facility, and staff interviews, it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings. Residents Affected - Some The findings include: A review of the facility's Grievance Policy, last revised by the facility January 14, 2019, revealed that This facility has a system in place to ensure the resident's right to prompt efforts to resolve grievances that they may have. The policy noted The reasonable timeframe within which the resident can expect a completed review of the grievance is within 5 to 7 business days. A review of the facility's grievance log dated August 2023, provided by the facility during the survey of January 22, 2024, revealed that there were no grievances lodged during the month of August 2023. However, the facility provided four grievances that were raised on August 24, 2023, through Resident Council, that were not included on the log. These complaints indicated that residents in attendance at the Resident Council meetings, expressed concerns that staff were not providing showers, staff using their personal phones and being on social media while working, and night shift staff being loud while residents are trying to sleep. There was no documented record of the facility's response to those grievances, including and corrective actions, or grievance resolution as of the time of the survey ending January 22, 2024. A review of facility grievance log dated September 2023, revealed that there was one grievance submitted during that month, on September 2, 2023. A grievance was submitted on September 14, 2023, following the Resident Council meetings during which a complaint was raised about residents being permitted to use chewing tobacco in a tobacco free facility. There was no documented record of the facility's response to those grievances, including and corrective actions, or grievance resolution as of the time of the survey ending January 22, 2024. The facility's grievance log dated October 2023, revealed that there were no grievances for the month of October 2023, but six complaints were raised at Resident Council on October 12, 2023, and not included on the log. These complaints included cold food, not receiving snacks, that nurse aides are (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 3 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 01/22/2024 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)