Pennsylvania Department of Health
EMBASSY OF TUNKHANNOCK
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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EMBASSY OF TUNKHANNOCK - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on March 31, 2025, at Embassy of Tunkhannock, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 551002
Component 01
Main Building
Based on a Medicare/Medicaid Recertification Survey completed on March 31, 2025, it was determined that Embassy of Tunkhannock was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).
This is a one story, Type II (000), unprotected, noncombustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Cooking Facilities:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review and interview, it was determined the facility failed to maintain cooking facilities in one instance, affecting one of one floor.

Findings include:

1. Observation on March 31, 2025, at 12:22 p.m., revealed the facility lacked one of two required ansul system inspections for the preceding twelve month period.

Exit interview with the Facility Administrator and the Facilities Manager on March 31, 2025, between 12:30 p.m., and 12:35 p.m., confirmed the cooking facilities deficiency.

Plan of Correction - To be completed: 04/25/2025

Facility cannot retroactively correct deficiency

Education provided to Maintenance Director on annual inspections for Ansul system

Maintenance Director scheduled inspection for 4/25/2025 of the automated fire suppression Ansul system. Vendor educated as to importance of timely inspections as scheduled each 6-month interval.

NHA/designee will review inspection binder including Ansul system biannually to ensure all inspections are completed. Results to the QA committee to ensure compliance.

NFPA 101 STANDARD Electrical Equipment - Other:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Electrical Equipment - Other
List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 10 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0919

Based on observation and interview, it was determined the facility failed to maintain electrical systems in one instance, affecting one of one floor.

Findings include:

1. Observation on March 31, 2025, at 11:55 a.m., revealed an unsecured junction box, located above the suspended ceiling assembly, within Room 104.

Exit interview with the Facility Administrator and the Facilities Manager on March 31, 2025, between 12:30 p.m., and 12:35 p.m., confirmed the electrical systems deficiency.

Plan of Correction - To be completed: 04/28/2025

Facility cannot retroactively correct deficiency

Facility audit of all junction boxes completed by maintenance director. All junction boxes were secured. Junction box cited during survey corrected at time of survey

Education provided to maintenance staff on security of junction boxes. Maintenance director/designee to audit junction boxes monthly X 3 months with results sent to the QA committee to ensure compliance.

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