Health inspection·December 3, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, facility policies, and staff interviews, it was determined the facility failed to ensure one of ten sampled residents (Resident 1) was free of a significant medication error resulting in the administration of incorrect doses on multiple occasions. Findings include:A review of facility policy titled Coumadin Monitoring Procedure revealed it is the responsibility of the nurse to update the MAR (Medication Administration Record) with the new Coumadin dose order, and the PT/INR (Prothrombin Time/International Normalized Ratio, blood tests used to measure how quickly blood clots) laboratory draw orders.A review of a facility policy titled Medication Administration revealed it is the responsibility of the nurse to compare the medication with the MAR to verify the right resident, medication name, form, dose, route and correct time of administration. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included dementia (a group of conditions that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life) and muscle weakness.A physician ' s order dated August 15, 2025, directed administration of Warfarin 2 mg by mouth (brand name Coumadin is a prescription anticoagulant medication/blood thinner used to prevent or treat blood clots by slowing the body ' s ability to form clots. It requires regular blood testing PT/INR to ensure the dose is safe and effective because too much can cause bleeding and too little can increase the risk of clotting) every Tuesday and Friday at 8:00 PM., which was discontinued on September 20, 2025. Another physician ' s order dated August 13, 2025, directed administration of Warfarin 3 mg by mouth every Monday, Wednesday, Thursday, Saturday, and Sunday at 8:00 PM, discontinued on September 20, 2025.A nursing progress note dated September 17, 2025, at 3:24 PM., documented a new order from the Coumadin clinic to administer Warfarin 5 mg by mouth once on September 17, 2025, and then to resume the prior alternating 2 mg and 3 mg schedule.A review of Resident 1 ' s September 2025 Medication Administration Record (MAR) showed that on September 17, 2025, the resident received two doses of Warfarin (Coumadin) 3 milligrams (mg) at 8:00 PM and 5 mg at 8:47 PM The total amount administered was 8 mg, even though the physician ' s order directed that only 5 mg be given that day.A review of Resident 1 ' s order summary for the same date revealed that when the nurse entered the new one-time order for Warfarin 5 mg on September 17, she also entered new standing orders for Warfarin 2 mg every Tuesday and Friday and Warfarin 3 mg every Monday, Wednesday, Thursday, Saturday, and Sunday at 9:00 p.m., but did not discontinue the older, duplicate Warfarin orders already in the system. Because the older and new orders were both active, the electronic medication record displayed multiple Warfarin doses, which led to additional doses being administered in error.As a result, Resident 1 received incorrect doses over several days:September 17, 2025: total of 8 mg instead of the ordered 5 mg.September 18, 2025: total of 6 mg instead of the ordered 3 mg.September 19, 2025: total of 4 mg instead of the ordered 2 mg.A review of the facility ' s medication-error investigation showed that these extra doses were discovered on Residents Affected - Few (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 2 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 12/03/2025 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)