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 (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 4 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 04/16/2025 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)