Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tunkhannock Rehabilitation & Health Care Center during CMS and state inspections, most recent first.
A resident with cerebral infarction, frequent falls, and behavioral disturbances, who required a wheelchair for mobility, experienced multiple falls, including two closely spaced falls during one night shift. After the second witnessed fall, the supervising RN and an LPN did not promptly assist the resident from the floor, with staff reports indicating the resident was left crawling and told he could get up on his own, and that no incident report or witness statements were needed. The DON and administrator confirmed that these nurses failed to follow the facility’s abuse/neglect and reporting policies and did not provide timely assistance and assessment after the fall, resulting in a finding of neglect.
Inaccurate MDS coding was found for two residents. One resident with dementia, hemiplegia, hemiparesis, cerebrovascular disease, and malnutrition had quarter side rails coded as a restraint without documentation that they restricted movement or met the restraint definition. Another resident with respiratory failure had an admission MDS that failed to show routine antipsychotic use, even though the physician ordered Quetiapine and the MAR showed nightly administration during the look-back period.
A resident with dementia, hyperlipidemia, and anxiety was admitted to hospice with end stage senile degeneration of the brain, and a comprehensive Significant Change MDS reflected hospice services. The record lacked documentation of the required IDT care plan meeting within the required timeframe, and there was no evidence that the physician, RN, resident and/or representative, and other relevant disciplines met to revise the care plan or integrate hospice services.
A resident with dementia, hemiplegia, hemiparesis, cerebrovascular disease, and moderate protein-calorie malnutrition had inconsistent weight monitoring, missed required weekly weights and reweights, and a significant weight loss was not timely identified or addressed. The record showed progressive decline in wt, fair to poor intake, and wound concerns, but documentation did not show timely implementation of ordered oral nutritional supplements such as Magic Cup and Ensure.
The facility failed to provide oxygen therapy in accordance with physician orders for two residents. One resident with acute and chronic respiratory failure with hypoxia had oxygen tubing that exceeded the weekly change interval, and another resident with MS had nasal cannula tubing and related oxygen supplies dated beyond the ordered weekly replacement schedule. An RN confirmed the dates on the tubing and supplies did not match the required change frequency, and the DON reviewed the findings.
A nurse aide failed to follow a care plan requiring two-person assistance for a resident with severe cognitive impairment and multiple medical conditions. The aide transferred the resident alone, left the resident unattended while silencing a bed alarm, and the resident fell from the wheelchair, sustaining multiple subdural hematomas and a scalp laceration that required hospitalization.
Failure to Provide Timely Assistance and Reporting After Witnessed Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not providing immediate assistance and assessment after a witnessed fall. The facility’s abuse, neglect, and exploitation policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, or mental anguish, including withholding or inadequately providing care or services necessary to maintain resident safety and well-being. Despite this policy, staff did not follow required procedures when a resident with a history of frequent falls and behavioral issues experienced a second fall and remained on the floor without prompt assistance. The resident, identified as having cerebral infarction, a history of frequent falls, and requiring a wheelchair for mobility, had multiple documented behavioral symptoms including confusion, hallucinations, verbal outbursts, and aggression toward staff. Clinical records and progress notes showed that the resident frequently attempted to ambulate without assistance, tried to exit through doors, and had prior falls, including one on March 13, 2026, and another on March 16, 2026, where the resident was assisted back to the wheelchair with no injury observed. On March 17, 2026, at approximately 2:50 AM, the resident attempted to stand from the wheelchair, which rolled backward, causing a fall to the right side. The supervising RN documented assisting the resident back to the wheelchair and assessing for injuries after this first fall. According to the facility’s investigative documentation and staff witness statements, a second fall occurred 10 to 15 minutes later when the resident again rose from the wheelchair, lost balance, and fell. The RN Supervisor reported that the resident was then observed crawling on the floor and stated that, due to the resident’s history of combative behavior, she did not assist him to a standing position until he verbalized readiness to return to the wheelchair. A nurse aide reported being told by the RN Supervisor that the resident could get up on his own and observed the resident crawling on the floor. Another LPN stated that when informed the resident was on the floor again and asked if staff should assist, the RN Supervisor responded that he would just throw himself on the ground again, and no incident report or witness statements were requested. The DON and Nursing Home Administrator later confirmed that the RN Supervisor and LPN did not follow the facility’s abuse and neglect policy related to resident protection and reporting requirements and failed to provide timely assistance after a witnessed fall, constituting neglect.
Inaccurate MDS Coding for Restraints and Antipsychotic Use
Penalty
Summary
The facility failed to complete accurate MDS assessments for two residents. For one resident with diagnoses including unspecified dementia, hemiplegia, hemiparesis, cerebrovascular disease, and moderate protein-calorie malnutrition, the quarterly MDS coded substantial to maximal assistance for rolling and transfers and indicated bedrails were used daily as a restraint in Section P-P0100. The clinical record showed right and left quarter side rails were in place, but it did not document that the rails restricted the resident’s freedom of movement, prevented voluntary exit from the bed, or otherwise met the definition of a restraint, and it did not identify the rails as a restraint or provide clinical justification for coding them that way. The Nursing Home Administrator acknowledged the Section P coding was an error. For another resident admitted with acute and chronic respiratory failure, the admission MDS documented that no antipsychotic drugs were administered during the assessment reference period and that no antipsychotic medication had been received since admission. However, the physician’s orders included Quetiapine Fumarate 25 mg at bedtime for depression with behaviors, and the MAR confirmed the resident received Quetiapine nightly during the assessment reference period. The RNAC acknowledged the admission MDS did not accurately reflect the resident’s routine daily use of an antipsychotic medication since admission.
Failure to Complete Required Interdisciplinary Care Plan After Comprehensive MDS
Penalty
Summary
The facility failed to follow its care plan process after a comprehensive assessment for one resident who was enrolled in hospice services. Resident 8 was admitted with diagnoses including dementia, hyperlipidemia, and anxiety, and later had a physician order for hospice services with a diagnosis of end stage senile degeneration of the brain. The clinical record showed a comprehensive Significant Change MDS assessment that reflected hospice services for the resident. The record did not contain documentation of a comprehensive interdisciplinary care plan meeting completed within seven days of the comprehensive MDS assessment. There was no evidence of a documented IDT meeting involving the physician, RN responsible for the resident, the resident and/or representative, and other relevant disciplines, and no documentation showing revision of the care plan or integration of hospice services into the comprehensive care plan during the required timeframe. Staff interviews confirmed the facility could not provide documentation that the required interdisciplinary care plan meeting occurred after completion of the Significant Change MDS.
Failure to Monitor Weight Loss and Implement Timely Nutritional Interventions
Penalty
Summary
The facility failed to monitor a resident’s weight consistently and accurately and did not timely identify and address significant nutritional decline. Resident 2 was admitted with unspecified dementia, hemiplegia, hemiparesis, cerebrovascular disease, and moderate protein-calorie malnutrition. The resident’s admission MDS showed moderate cognitive impairment, and the comprehensive care plan identified the resident as at risk for nutritional decline related to the resident’s diagnoses and history of pressure wounds, with goals to maintain adequate nutritional status and stable weight. Facility policy required admission and follow-up weights, weekly weights for newly admitted residents, reweights for significant fluctuations, and notification of the physician, DON, and RD for significant weight changes. The resident’s weight was recorded on admission and again several weeks later, but the facility did not obtain the required weekly weights. After a recorded weight of 130 pounds, the next weight was 119.6 pounds, reflecting a loss of 10.4 pounds, or about 8 percent in one month. The facility did not obtain a next-day reweight as required by policy, and the clinical record did not show that the RD identified and addressed the significant weight loss during that interval. The record also showed progressive weight decline and wound concerns without timely documented implementation of nutritional interventions. A nutrition note documented fair intake and new wounds, and the care plan later listed Prosource, Magic Cup, and Ensure, but the facility could not provide documented evidence that Magic Cup or Ensure were timely implemented after the significant weight loss was identified. Weights continued to fall over the following months, with additional dietary notes documenting continued significant weight loss, fair to poor intake, and family providing extra food and encouragement. During interview, the NHA and DON confirmed the facility could not provide documentation showing timely weight monitoring, timely reweights, or timely implementation of oral nutritional supplementation to address the resident’s progressive weight loss and associated wound development.
Oxygen Tubing Not Changed Per Physician Orders
Penalty
Summary
The facility failed to ensure oxygen therapy was administered in accordance with physician orders and professional standards for two residents. Facility policy required oxygen therapy to be provided in a safe manner consistent with physician orders and the resident’s care plan. Resident 45 was admitted with acute and chronic respiratory failure with hypoxia and had a physician order for oxygen at 3 L/min via nasal cannula with oxygen tubing and humidifier to be changed weekly. On observation, Resident 45 was receiving oxygen by nasal cannula connected to an oxygen tank, and the tubing was dated February 5, 2026, which exceeded the ordered seven-day change interval. An RN confirmed the tubing should have been replaced every seven days and that the date exceeded the ordered duration. Resident 29 was admitted with relapsing remitting multiple sclerosis and had a physician order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath, with instructions to check liter flow and placement every four hours and to change the oxygen tubing, bubble humidifier, rinse filter, and date the tubing and humidifier weekly. During observation, the resident’s nasal cannula tubing was dated February 5, 2026, and a clear plastic bag used for storing oxygen tubing was also dated February 5, 2026. An RN confirmed both the tubing and bag were dated February 5, 2026. The DON reviewed the findings related to the facility’s failure to maintain respiratory equipment in a manner to promote optimal functioning.
Failure to Follow Two-Person Transfer Protocol Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide failed to follow the care plan for a resident with severe cognitive impairment and multiple medical conditions, including atrial fibrillation, a history of stroke, and hypertension. The resident required two-person assistance for transfers due to confusion, musculoskeletal impairment, and a history of falls. Despite this, the nurse aide transferred the resident alone from bed to wheelchair, which was not in accordance with the resident's care plan interventions. During the transfer, the bed alarm was triggered, and the nurse aide turned her back to silence it, leaving the resident unattended. As a result, the resident fell forward out of the wheelchair and sustained a large hematoma and a bleeding forehead laceration. The resident was found barefoot, without appropriate footwear or non-skid socks, and was lying face down on the floor. Emergency services were contacted, and the resident was transported to the hospital for evaluation and treatment. Hospital records confirmed that the resident suffered multiple subdural hematomas, a subarachnoid hemorrhage, and a significant forehead laceration, requiring admission to the Progressive Care Unit for several days. Facility documentation and staff interviews substantiated that the nurse aide did not follow the required two-person transfer protocol, directly resulting in the resident's injuries and hospitalization.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tunkhannock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Embassy Of Tunkhannock | 0.2 mi | ★★★★★ | 22 | 1 |
| Kadima Rehabilitation & Nursing At Lakeside | 13.7 mi | ★★★★★ | 17 | 0 |
| Abington Manor | 14.6 mi | ★★★★★ | 21 | 0 |
| Meadows Nursing And Rehabilitation Center | 15.1 mi | ★★★★★ | 3 | 0 |
| Highland Manor Rehabilitation And Nursing Center | 15.6 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.