TUNKHANNOCK, PA - Federal inspectors have identified significant violations at Embassy of Tunkhannock, a nursing facility where residents reported persistent problems accessing snacks and where staff failed to properly assess care needs for dozens of residents with dementia.
Chronic Snack Distribution Problems Persist Despite Resident Complaints
The most troubling violation centered on the facility's failure to provide adequate snack service to residents, an issue that persisted for months despite multiple formal complaints. Six residents interviewed during the March 2025 inspection reported they were not regularly offered snacks, a basic nutritional service that nursing homes are required to provide.
The problem became so persistent that residents filed formal grievances in December 2024 and again in February 2025. One resident's December complaint specifically noted that "No snacks readily available, or if snacks are available the bowl of snacks are on top of the fridge - unreachable."
According to the facility's own written policy, snacks should be provided between meals when ordered and in the evening for residents who request them. The policy also specified that evening snacks would be delivered to nurses' stations, where staff would offer them to residents and document intake. However, inspectors found this policy was not being followed consistently.
During the inspection, surveyors observed snack containers placed on top of unit refrigerators, making them inaccessible to wheelchair-bound residents and those with mobility limitations. This placement effectively prevented many residents from obtaining snacks independently, requiring them to ask staff for assistance that was not consistently provided.
Medical Implications of Inadequate Snack Service
Proper nutrition timing is critical for nursing home residents, particularly those taking medications that require food intake or residents with diabetes who need regular blood sugar management. Between-meal snacks serve multiple medical purposes beyond basic nutrition, including medication compliance, blood glucose stabilization, and maintaining adequate caloric intake for residents who may eat smaller portions at regular meals.
For elderly residents, extended periods without food can lead to hypoglycemia, medication side effects, and increased fall risk due to weakness or dizziness. Additionally, residents with swallowing difficulties may rely on frequent, smaller meals and snacks to meet their daily nutritional requirements safely.
The facility's Director of Nursing acknowledged during the inspection that snack distribution issues had been raised multiple times by residents and confirmed that each unit should maintain adequate snack supplies to accommodate various dietary needs and texture requirements for bedtime snacks.
Inadequate Assessment of Dementia Care Needs
Inspectors identified a second major violation involving the facility's failure to conduct a comprehensive assessment of resources needed to care for residents with dementia. The facility housed 24 residents with documented dementia diagnoses among its 71-resident population, yet its facility-wide assessment contained outdated and inaccurate information about available specialized care services.
The facility's assessment document incorrectly described having a secured Memory Care Unit with specialized programming and additional activity hours. However, inspectors found no locked memory care unit existed at the time of the survey. All 24 residents with dementia were living throughout the general facility without the specialized environment described in the assessment.
This misrepresentation in the facility assessment had real consequences for resident care. During observations, 10 residents with advanced dementia were found sitting in an activity room watching television cartoons for hours without meaningful engagement. Despite posted activity schedules showing "Trivia and Word Games" and "1 to 1 visits," no structured activities were provided.
Industry Standards for Dementia Care
Modern dementia care requires specialized programming designed to maintain cognitive function, reduce agitation, and provide meaningful engagement appropriate to residents' abilities. Effective dementia care typically includes structured activities, consistent routines, environmental modifications, and staff trained in dementia-specific communication techniques.
Placing residents with dementia in front of a television without interaction fails to meet accepted standards of care and can contribute to further cognitive decline, increased agitation, and social isolation. Research consistently shows that meaningful activities and social interaction can slow cognitive decline and improve quality of life for residents with dementia.
A Licensed Practical Nurse told inspectors that the television was used primarily "to keep them in one area for easier staff monitoring rather than to provide meaningful engagement." This approach prioritizes convenience over therapeutic benefit and does not align with person-centered care principles required in nursing facilities.
Staffing and Resource Allocation Issues
The facility's Activity Director acknowledged during the inspection that the facility lacked adequate activity staff to provide specialized dementia care programming. Evening activity programming was described as minimal, with little to no structured activities offered during evening hours when residents with dementia often experience increased confusion and agitation.
Federal regulations require nursing facilities to conduct comprehensive assessments that accurately reflect resident needs and available resources. These assessments must consider staffing requirements for both routine operations and emergency situations. The facility's assessment failed to address how available resources were being allocated to ensure compliance with care requirements.
Additional Issues Identified
Inspectors documented several other areas of concern during the March 2025 survey. The facility's response to resident grievances showed awareness of problems but inadequate follow-through on corrections. Despite posting memorandums directing staff to offer snacks regularly and conducting staff education with signed forms, the problems persisted for months.
The inspection also revealed gaps in the facility's quality assurance processes, as management was aware of recurring complaints but had not implemented effective corrective measures. The facility-wide assessment had not been updated to reflect the actual care environment or specialized needs of the dementia population.
The violations highlight broader systemic issues with care planning, staff training, and resource allocation that affected the daily lives of residents who depend on the facility for comprehensive care services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gardens At Tunkhannock, The from 2025-03-21 including all violations, facility responses, and corrective action plans.
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