Health inspection·April 16, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on review of clinical records, select facility policy review, and staff interview it was determined that the facility failed to ensure that one resident out of five sampled was free of chemical restraints used to most readily control the resident's behavior and not required to treat the resident's medical symptoms (Resident 1). Findings include: A review of the Facility's Policy labeled Restraint Free Environment last reviewed by the facility on June 1, 2024, reviewed on April 15, 2025, at approximately 1:30PM defines a chemical restraint as any medication that is used for discipline or staff convenience, and not required to treat medical symptoms. The policy further revealed the resident's medical record must include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint and the effectiveness of the restraint in treating the medical symptom. A review of Resident 1's clinical record revealed admission to the facility on March 4, 2024, with diagnoses to include vascular dementia with behavioral disturbance (a condition caused by impaired blood flow, characterized by poor judgement and memory impacting daily functioning) and anxiety disorder (a disorder characterized by excessive worry and fear that can significantly impact daily life.) A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 11, 2025, revealed the resident was severely cognitively impaired with no BIMS score available (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information). A review of the resident's clinical record revealed the following orders: November 22, 2024- Compound lorazepam gel (Ativan a benzodiazepine antianxiety medication topical gel in semisolid form dispensed through a pump mechanism that allows for easy application to the skin for absorption of the medication) apply to wrist topically at 1:00PM daily. January 3,2025- Compound lorazepam gel apply to wrist topically every 8 hours as needed (PRN) for anxiety, in addition to the lorazepam gel being applied in the afternoon at 1:00 PM. In addition to these orders the resident was also prescribed Depakote 750 mg (a medication used to manage agitation and other behavioral symptoms) via oral route daily and Zoloft 25mg via oral route Page 1 of 4 395433 395433 04/16/2025 Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few daily (a selective Serotonin Reuptake inhibitor medication used to manage mood and behavioral symptoms in people with dementia). A review of the medication administration record revealed the resident was administered the as needed dose (PRN) lorazepam gel in addition to the 1:00PM dose of lorazepam gel on the following dates without any supporting documentation of increased anxiety or behaviors: January 6, 2025, at 07:54 AM January 7, 2025, at 02:40AM January 9, 2025, at 07:11PM January 23, 2025, at 07:52PM January 27,2025 at 6:26 PM February 8, 2025, at 3:09 PM February 10, 2025, at 6:27PM February 15, 2025, at 5:53 PM A review of the resident's clinical record revealed the resident had no contraindication for taking oral medications. Further record review revealed that all other medications administered to the resident were administered via the oral route. Observation of the resident on April 15, 2025, at 09:00AM revealed the resident sleeping in the common area of the facility, not easily arousable. A second observation at approximately 10:30AM revealed the same. A third observation at 12:30 PM revealed the resident awake and communicating with other residents. During an interview with the Director of Nursing (DON) on April 15, 2025, at 09:00AM, the DON stated the lorazepam gel had been initiated in November 2024 due to the resident refusing oral lorazepam. However, the facility failed to provide any documented evidence the resident was unable to tolerate oral medications. The resident's current psychotropic medications, Depakote and Zoloft, were both administered orally without documented difficulty. The use of lorazepam gel in this case, in the absence of documented behaviors, medical symptoms, or an inability to take oral medications, suggests the medication was not used for the treatment of a specific medical condition, thus constituting a chemical restraint. Because the resident was assessed as severely cognitively impaired, she lacked the capacity to make informed decisions or express refusal regarding her medication regimen. The lorazepam gel was applied to the resident's skin on the wrist without evidence of consent or objection, despite the absence of documented medical symptoms at the time of administration. This prevented the resident from participating in decisions about her care and eliminated any ability to refuse the medication, further supporting the classification of the lorazepam gel as a chemical restraint. 395433 Page 2 of 4 395433 04/16/2025 Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of a facility policy labeled Medication Regimen Review last reviewed by the facility June 1, 2024, revealed PRN (as needed) medications are limited to 14 days. To extend a PRN order past 14 days, the prescriber must document their rationale in the medical record and indicate the duration for the PRN order. The resident's clinical record failed to contain evidence the prescriber had a documented rationale in the medical record for the extended period of the as needed medication (PRN) administration past 14 days. An interview with Employee 1 NA (nurse aide) revealed the resident is usually groggy and not easily arousable until around 12:00PM each day. He revealed the resident would display certain behaviors usually in the afternoon. The facility failed to show evidence a less restrictive alternative treatment was attempted based on an appropriate assessment, care planning by the interdisciplinary team, and physician documentation of the medical symptoms. The resident's clinical record failed to contain evidence the facility staff and/or physician had identified, to the extent possible, and addressed the potential underlying causes of Resident 1's behavior such as environmental factors and over stimulation. During an interview with the Director of Nursing (DON) on April 15, 2025, at approximately 12:00PM, the DON confirmed the facility failed to provide documented evidence the resident was experiencing symptoms that would warrant nursing staff to administer the as needed (PRN) medication or the resident was unable to tolerate an oral method of medication administration. 28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services 28 Pa. Code 211.8 (e) Use of restraints 28 Pa. Code 211.5(i)(ii)(viii)(xi) Clinical records 28 Pa. Code 211.9(b)(2) Pharmacy services 28 Pa. Code 211.2(3) Physician Services 395433 Page 3 of 4 395433 04/16/2025 Embassy of Tunkhannock 30 Virginia Drive Tunkhannock, PA 18657

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on observation, select facility policy review, review of clinical records, and staff and resident interview, it was determined the facility failed to consistently provide timely and necessary foot care for one of eight residents sampled (Resident 1). Residents Affected - Few Findings include: A review of the Facility's Ancillary Staff Policy last reviewed January 1, 2025, revealed it is the facility's responsibility to assist resident in obtaining routine and emergency ancillary services as needed including Podiatry. The policy then explains podiatry services include everything from toenail trimming to foot exams. A review of Resident 1's clinical record revealed admission to the facility on March 4, 2024, with diagnoses to include vascular dementia with behavioral disturbance (a condition caused by impaired blood flow, characterized by poor judgement and memory impacting daily functioning) and anxiety disorder (a disorder characterized by excessive worry and fear that can significantly impact daily life.) A Quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 11, 2025, revealed the resident was severely cognitively impaired with no BIMS score available (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information). On April 16, 2025, at approximately 09:30AM, observation of Resident 1 revealed the toenails on the right foot were long, extending beyond the tips of the toes with evidence of redness around the sides of the toenails. A review of Resident 1's clinical record showed the resident was seen by Podiatry on June 10, 2024, revealing thickening and discoloration of the toenails. The diagnosis from podiatry was onychomycosis (a fungal infection of the toenails) with a treatment of debridement (a medical procedure on the above date. Further review revealed the resident was seen by Podiatry again on August 19, 2024, revealing the resident complained of painful, thick toenails. The exam revealed thickening, yellow, brittle nails. The diagnosis from podiatry was onychomycosis with a treatment of debridement on the above date August 19, 2024. Further clinical record review revealed the resident has not been seen by Podiatry since August 19, 2024. Interview with the Director of Nursing (DON) at approximately 1:00PM revealed the facility switched podiatry providers on September 1, 2024. The DON confirmed the resident has not received routine podiatry care as of April 16, 2025. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing Services 395433 Page 4 of 4