Health inspection·May 21, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of the medication/treatment supply room on the [NAME] Wing on May 20, 2024, at 9:34 AM revealed the sink was heavily soiled and stained with a greenish-blue substance. There was thick brown sludge-like substance coating the faucet and each water turn on knob. The base of the sink was coated with the same brown/black sludge-like substance. Beneath the sink there was a pink plastic wash basin setting beneath the sink pipe. The basin was coated with a thick layer of brown/black substance. The cabinet frame was heavily soiled with a brown/tan substance. Ceiling tiles above where the medication cart is stored when not in use were heavily water stained. An observation on May 20, 2024, at 9:41 AM revealed the medication/treatment supply room on the Blue Wing had a large hole in the wall next to the heating/ac unit that was covered with plastic and secured with blue painter's tape. The cabinet beneath the sink was heavily stained/soiled with a rust-colored substance, dirt, and debris. Interview with Employee 6, licensed practical nurse, revealed that there were dead animals in the wall that had to be removed. At the time of the observation, the air conditioning was set on high, and there were air fresheners placed on the air conditioning unit. Observation of the Blue Wing resident care unit on May 20, 2024, at 9:49 AM revealed multiple water-stained ceiling tiles outside the resident kitchenette and resident shower room. Ceiling tiles next to the vents in the same area were heavily soiled with black dust/lint. Interview with NHA on May 20, 2024, at approximately 10 AM, confirmed that there were dead squirrels in the wall that needed to be removed. According to the NHA, the facility was waiting on supplies to repair the hole. The NHA further stated that purchase orders were submitted for new drawers/dressers for the resident rooms yet was unable to provide evidence to surveyors that replacement items were on order or that the need for repairs had been identified and/or addressed prior to survey. An observation on May 20, 2024, at 11:08 AM in the Nursing Blue Hall resident laundry room revealed a sink with multiple rust spots and a faucet that continued to run when in the off position. Repeat observation of the Blue Wing medication/ treatment supply room at 1:20 PM, revealed that the hole in the wall was repaired. The plastic had been removed and was replaced with an electrical outlet and outlet cover. Interview with the Nursing Home Administrator on May 21, 2024, at approximately 2 PM confirmed that the residents' environment was to be maintained in a clean and sanitary manner. Refer F867 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395433 If continuation sheet Page 2 of 8 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 05/21/2024 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)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of facility's planned meal tickets, and resident and staff interviews it was determined that the facility failed to accommodate residents' food preferences, and provide foods planned for oral gratification for one resident of 20 residents reviewed (Resident 32). Findings included: A review of resident 32's clinical record indicated she was most recently admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD), diabetes, and gastroparesis (a condition which affects the stomach muscles and prevents proper stomach emptying). The resident's care plan, dated August 15, 2016, included a focus area of Nutrition, revealing the resident is dependent on tube feeding related to duodenal stricture, gastroparesis with a planned included that the resident is NPO (nothing by mouth, ice chips, clear Gatorade, coffee, and lemon Italian ice allowed) see orders section of medical chart, date revised December 13, 2022. The resident's care plan, also included the problem/need of socialization, date-initiated July 7, 2023, with an intervention that staff is to offer resident lemon Italian ice or coffee during social as alternative due to dietary restrictions, initiated April 26, 2024. A review of current physician orders dated June 30, 2023, revealed that the resident was to receive an enteral tube feeding every shift, give 45 ml/hr of Isosource 1.5 for 20 hrs. via J tube document amount administered each shift and document. Observation of the lunch meal on May 18, 2024, at approximately 12:20 PM, revealed that Resident 32's tray card [is a menu-based document that provides essential information about a resident ' s meal such as diet order, preferences, food allergies, dislikes, dining location, supplements, and adaptive equipment (if required) and helps staff accurately prepare and serve meals to residents based on their individual needs and preferences] indicated that her lunch items were to include 2 lemon ice, and hot coffee, (may have ice chips or Italian ice). During this observation the surveyor observed that the resident's lunch tray revealed that the resident was not served lemon ice, or Italian ice. Interview with the the alert and oriented, cognitively intact resident at that time the resident stated she never gets it (referring to the lemon or Italian ice) According to the resident she is exhausted asking for it, and that staff is well aware of her continued requests/complaints of not receiving it on her meal tray A second observation of the lunch meal on May 19, 2024, at approximately 12:15 PM, revealed that Resident 32's tray card indicated that her lunch items were to include 2 lemon ice, and hot coffee, (may have ice chips or Italian ice). During this second observation the surveyor observed that the resident was again not served lemon ice, or Italian ice on her lunch tray. During an interview with the Nursing Home Administrator (NHA) on May 19, 2024, at approximately 1:45 PM, the NHA stated that the facility's policy requires Resident 32 to purchase her own Italian lemon ice. The meal ticket for the resident's lunch time indicated that 2 Lemon ice are to be served, and that the resident's care plan indicated staff is to offer lemon Italian ice in activities. The NHA stated that staff are to offer the lemon Italian ice during activities. The surveyor requested the facility policy that indicated the resident is to purchase her own lemon Italian Ice, the NHA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395433 If continuation sheet Page 3 of 8 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 05/21/2024 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)

F 0806 replied, it is my policy. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 211.6 (a) Dietary services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395433 If continuation sheet Page 4 of 8 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 05/21/2024 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)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of the minutes from Resident Council Meetings, scheduled facility mealtimes, and select facility policy, and resident and staff interviews, it was determined that the facility failed to consistently provide snacks as desired by residents including 3 out of the 20 residents sampled (19, 30, and 37) and experiences reported by residents during a group interview (Residents 61 and 73). Findings include: A review of the facility's policy titled Policy: Frequency of Meals, last reviewed in July 2023, indicated that nourishing snacks will be available for residents who need or desire additional food between meals. The policy indicates that residents will be offered nourishing snacks if the time span between the evening meal and the next day's breakfast exceeds fourteen hours. A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds fourteen hours. A review of resident council meeting minutes dated April 12, 2024, revealed that all residents in attendance indicated that they were not receiving snacks. The meeting minutes indicated that a grievance was filed on behalf of the residents in attendance. The facility provided daily water and snack pass forms to be completed and signed by a nurse aide and licensed nurse to indicate that water and snacks were passed. Six of the 13 forms had no signature indicating that water or snacks were passed on the 2:00 PM to 10:00 PM shift (evening shift). Six of the 13 forms reviewed had no date to confirm when the task was completed. During the resident group interview on May 20, 2024, at 10:00 AM, all residents in attendance (Residents 19, 30, 37, 61, and 73) indicated that they were not being offered evening snacks. The residents explained that about once or twice a month they are offered snacks, but the majority of the time they have to ask staff for assistance or get their own snack. The residents indicated that the facility runs out of snacks, and on several occasions, no snacks were available when requested by residents. The residents explained that the facility is aware of this concern; however, the problem has not been resolved. The residents indicated that the facility is often short on nurse staffing and that there may not be enough staff to offer snacks to the residents every evening. During an interview on May 21, 2024, at 10:30 AM, the Nursing Home Administrator (NHA) was unable to explain why Residents 19, 30, 37, 61, and 73 are indicting that the facility is not offering nutritious snacks. The NHA stated that the facility does not evaluate snack inventory level to ensure snacks are consistently available to meet residents needs. Refer F565 28 Pa. Code 211.12 (d)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395433 If continuation sheet Page 5 of 8 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 05/21/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Review of a facility policy titled Food Storage that was provided by the facility on May 20, 2024, indicated that food storage areas shall be maintained in a clean, safe, and sanitary manner. Guidelines for food storage included the following: • Food storage areas shall be clean at all times. • All packaged food, canned foods, or food items stored shall be kept clean and dry at all times. • All foods stored in walk-in refrigerators and freezers shall be stored above the floor on the shelves, racks, dollies, or other surfaces that facilitates thorough cleaning. All food will be dated at time of receipt and be inventoried using the FIFO (first in, first out) method. • Bulk items such as flour, sugar, oatmeal, etc. shall be stored in covered plastic bins. These should be labeled and dated clearly and appropriately. The initial tour of the kitchen was conducted on May 18, 2024, at 8:38 AM, that revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: Observed a rack of clear plastic beverage pitchers that had an accumulation of a white substance coating the surfaces. Above the beverage station, observed a ceiling tile that had tan colored circular staining and the top of the coffee maker had an accumulation of dust adhered to the surface. Also, behind the coffee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395433 If continuation sheet Page 6 of 8 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 05/21/2024 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)

F 0812 maker and on the molding of the stainless-steel table there was an accumulation of debris and dust. Level of Harm - Minimal harm or potential for actual harm Observations of another food/beverage preparation station revealed that the shelving had debris present and stained serving trays with dishes on the tray and were not covered. The trays that had thermal cups that were on a tray that was stained. Residents Affected - Many Observations of the walk-in freezer revealed that the door latch was broken and did not make contact with the latch to secure the door closed. Upon entry, the air curtain was ill-fitting, covered in frost, and had icicles hanging off the plastic strips and dripping on to the floor. The entry way floor was covered in a thick coating of ice that was slippery. Additionally, observed that the cases of frozen food were encased in ice crystals and observed three cases of frozen food left in direct contact with the floor. Observed that there was a free-standing black colored fan that was pointed at the walk-in freezer door that was covered with debris and dust. The ceiling tiles near the tray line area were splattered with a brown-colored substance and the ceiling light covers had several dead bugs accumulated on the inside. Further observations of revealed that there was a dirty broom leaning between the wall and kitchen preparation equipment. Observed that microwave, near the tray line, had food splattered on the handle. Additionally, there were two plastic containers of serving utensils placed inside with the handles at the bottom of the container and left uncovered. The cook's sink had a green cutting board that was placed between the wall and faucet and was observed with deep knife marks and worn. In the cook's area, observed a black mobile cart with two eight-quart clear plastic storage containers with cereal inside and were not labeled or dated. Observed that the wall exiting the cook's area was peeling and the tile baseboard behind was crumbling that left a gap between the wall and tile. Observed that ceiling tiles in the dish room area had a tannish-brown colored substance splattered on them. An observation conducted on May 18, 2022, at 9:11 AM, of the green unit resident pantry revealed that the there was a ceiling tile near a vent that had brown circular stains. The top of the refrigerator had debris and dust, an uncovered thermometer, and a blue basket with food remnants. Additionally, observed that the blue unit resident pantry had reddish colored stains on the floor around the perimeter of the refrigerator. During an interview with the Nursing Home Administrator on May 20, 2024, at 10:39 a.m., confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395433 If continuation sheet Page 7 of 8 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 05/21/2024 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)

F 0812 the above observations and that dietary department, and dietary equipment, and resident pantry areas should be maintained in a sanitary manner to prevent opportunities for foodborne illness. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18 (e) (2.1) Management Residents Affected - Many 28 Pa. Code 211.6 (f) Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395433 If continuation sheet Page 8 of 8