Health inspection·September 6, 2024

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on a review of facility policy, the minutes from facility Resident Council meetings, and grievances lodged with the facility, and resident and staff interviews, it was determined the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings and verbal grievances, including those voiced by four residents attending a resident group meeting (Residents 46, 57, 16, and 35) and failed to keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution. Residents Affected - Some Findings include: A review of the facility's Grievance Policy, last revised on June 1, 2024, indicated the facility has a system in place to ensure the resident's right to prompt efforts to resolve grievances that they may have. A review of the minutes from the Residents' Council meeting dated June 2024 indicated the residents in attendance at that meeting reported call bells were not being answered timely. A review of the minutes from the Residents' Council meeting dated July 2024 revealed the residents in attendance at this meeting complained that snacks are not distributed to residents consistently in the evenings before bed and continued to express concerns with timely call bell response. A review of the minutes from the Residents' Council meeting dated August 2024 revealed the residents in attendance at this meeting continued to complain that snacks are not distributed to residents consistently in the evenings before bed and continued concerns with timely call bell response. A group meeting conducted with five residents (Residents 46, 57, 16, and 35) on September 5, 2024, at 10:30 a.m. revealed all residents reported the facility was not addressing their complaints regarding the lack of consistent distribution of snacks and call bell response times. The facility was unable to provide documented evidence at the time of the survey ending September 6, 2024, the facility had determined if the residents' felt that their complaints or grievances had been resolved through any efforts taken by the facility in response to the residents not receiving snacks and call bell timeliness. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 06, 2024, at 9:10 a.m., the NHA and DON were unable to provide documented evidence that resident grievances raised at resident group meetings were timely addressed and the residents informed of the facility's efforts to resolve their complaints 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18 (e)(1)(4) Management 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 2 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observations, review of select facility policy, and staff interviews, it was determined the facility failed to develop a comprehensive grievance policy and ensure the necessary information for filing a grievance was posted and/or provided/available to residents or their representatives. Findings include: A review of the facility's policy entitled Resident and Family Grievances (last revised June 1, 2024) indicated it is the facility's policy that all grievances and complaints filed will be investigated and corrective actions will be taken to resolve the grievance. The policy failed to include procedures designed to support the resident's right to file a grievance anonymously, and failed to identify the current grievance official. Observations of the nursing units conducted on September 5, 2024, revealed a posting regarding the facility's grievance policy, which failed to include procedural information to include: where the grievance forms are located, how to file anonymously with the contact information of the grievance official with whom a grievance can be filed; to include a business address (mailing and email) and a business phone number; the right to obtain a written decision regarding his or her grievance; and a reasonable expected time frame for completing the review of the grievance. During an interview on September 6, 2024 at 10:00 AM with the Nursing Home Administrator and Director of Nursing, acknowledged the facility failed to post or provide residents the necessary details of the grievance process to include procedures to identify the grievance official and the procedure for filing an anonymous grievance including the locations of boxes to place anonymous grievances. 28 Pa. Code 201.18(b)(2) Management 28 Pa. Code 201.29(a)(i) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 3 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to include, in the resident's baseline plan of care, minimum standards of care to fully address the resident's immediate needs upon admission for one resident out 6 sampled (Resident B1). Findings include: A review of a facility policy entitled Resident admission Procedure (no date of policy development) that was provided by the facility on November 1, 2024, indicated the upon a resident's admission to the facility the nurse was to measure and record the resident's temperature, pulse, respiration, blood pressure, weight, and height. The nurse was to observe the general condition of the resident's skin (i.e., wounds, rashes, burns, bruises, scars, or surgical incisions), as well as his or her reaction to the admission. Additionally, the nurse was to notify the administrator, Director of Nursing (DON), attending/other involved physicians of the admission and acute issues such as respiratory or other distress, wounds, etc. that may need immediate attention. Determine if follow-up or other appointments are needed and complete the admission assessment and documentation. A review of Resident B1's clinical record revealed the resident was admitted to the facility on [DATE], with a cutaneous abscess (cavity filled with puss) of the buttocks, colostomy, Fournier gangrene (a type of necrotizing fasciitis, a flesh-eating disease that affects the scrotum, penis, or perineum), diabetes, and a scrotal abscess. A review of nursing progress notes in Resident B1's clinical record revealed a general progress note completed by Employee 1, a Registered Nurse (RN), dated October 29, 2024, at 9:28 PM, revealed the resident was alert and oriented to person, place and time, able to make his needs known and denied pain. Resident has a colostomy to left lower abdomen, scrotal wound measuring 6 cm x 3 cm x 5cm and a sacrum wound with 100% slough measuring 7 cm x 4 cm 1cm with a catheter for sacral wound irrigation. The resident utilized a PICC Line (a peripherally inserted central catheter, is a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart and is used to deliver medications and other treatments directly to the large central veins near the heart) to right upper arm with double lumen. Further review of Resident B1's baseline care plan (required to be developed within the first 48-hours of admission) failed to identify the resident's multiple skin impairments that required specific care and services and a PICC line to administer IV (intravenous) antibiotics. Additionally, the care plan failed to identify any goals and objectives and failed to include interventions that address the resident's current needs related to his medical conditions. Interview with the Director of Nursing on November 1, 2024, at 4:26 PM, confirmed the facility failed to sufficiently address the care and management of Resident B1 on the resident's baseline plan of care. 28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 4 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on review of select facility policy and interviews with residents and staff, it was determined the facility failed to review and revise the resident's plan of care in response to a significant weight loss for one resident out 18 residents (Resident 66). Findings include: Review of the clinical record of Resident 66 revealed admission to the facility on September 20, 2023, with diagnoses to include anoxic brain damage (brain damage from a lack of oxygen to the brain). On August 20, 2024, the resident weighed 81 pounds which was a 14.7% weight loss in 180 days. A nutritional note dated August 22, 2024, revealed that the dietitian has continued to implement interventions to address the residents weight loss, however a review of residents care plan, dated as last revised on May 30, 2024, revealed he resident was nutritionally at risk related to cardiovascular disease, diabetes, renal disease, respiratory disease, swallowing problems, NPO (nothing by mouth) requiring tube feeding, hypernatremia (high sodium levels in the blood), and hyperglycemia (high sugar levels in the blood). Upon review during the days of the survey, September 4-6, 2024, there were no updates or revisions to this resident's care plan related to the resident's nutritional risk and weight status since May 30, 2024. There was no documented evidence that Resident 66's care plan had been reviewed and revised related to current individualized interventions to address the resident's significant weight loss and continued need to monitor the resident's weights. Interview on September 5, 2024, at 2:30 p.m. the Nursing Home Administrator (NHA) confirmed the facility failed to review and revise Resident 66's plan of care to accurately reflect the resident's current status and needs. 28 Pa. Code 211.11(d) Resident care plan. 28 Pa. Code 211.12(d)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 5 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for one of 6 residents reviewed. (Resident A1). Residents Affected - Some Findings include: According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice. Chapter 21.145b. IV therapy curriculum requirements; (f) An LPN may perform only the IV therapy functions for which the LPN possesses the knowledge, skill and ability to perform in a safe manner, except as limited under § 21.145a (relating to prohibited acts), and only under supervision as required under paragraph (1). (1) An LPN may initiate and maintain IV therapy only under the direction and supervision of a licensed professional nurse or health care provider authorized to issue orders for medical therapeutic or corrective measures (such as a CRNP, physician, physician assistant, podiatrist or dentist). (g) An LPN who has met the education and training requirements of § 21.145b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under § 21.145a and only under supervision as required under subsection (f): (1) Adjustment of the flow rate on IV infusions. (2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 6 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0658 (3) Administration of IV fluids and medications. Level of Harm - Minimal harm or potential for actual harm (4) Observation of the IV insertion site and performance of insertion site care. Residents Affected - Some (5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes. (6) Discontinuance of a medication or fluid infusion, including infusion devices. (7) Conversion of a continuous infusion to an intermittent infusion. (8) Insertion or removal of a peripheral short catheter. (9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders. (10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route. (11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system. (12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions. (13) Collection of blood specimens from an IV access device. There was no facility policy and procedure provided to the survey team at the time of the survey. The Director of Nursing stated to the survey team on November 1, 2024 at 5:00 PM that LPNs may not administer or withdraw fluids via a venous central line (PICC line). Clinical record review revealed that Resident A1 was admitted to the facility on [DATE] with diagnosis to include, bilateral lower extremity wounds, sepsis (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever) and was admitted to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart). Physicians orders dated October 10, 2024 revealed, administer Cefepime HCL (intravenous antibiotic) 2 grams IV (intravenously) every 8 hours for bilateral lower extremity wounds with no discontinuation date indicated. A review of the October 2024 Medication Administration Record (MAR) revealed that between October 10, 2024 through October 31, 2024, Employee 2, LPN, Employee 3, LP, Employee 4, LPN, Employee 5, LPN, Employee 6, LPN, Employee 7, LPN, Employee 8, LPN and Employee 9, LPN signed the MAR as administering the IV antibiotic medication to Resident A1 through the PICC line. Interview on November 1, 2024, at approximately 5:00 PM with Employee 10, LPN, stated he never administered medications through any resident's PICC lines at the facility. He confirmed he was never educated on the administration of medications through the PICC line. He stated he would call the RN to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 7 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administer the IV through the resident's PICC line. He stated he, the LPN, would sign out on the MAR that he had administered the medication when the RN actually administered the IV medication through the resident's PICC line. There was no evidence of any current education or supervision regarding IV administration as well as PICC line usage for any LPNs working at the facility. During an interview on November 1, 2024, at approximately 5:30 PM the director of nursing (DON) stated that in the past several years that a few LPN's in the facility received education regarding the administration of medications through PICC lines. She could not provide evidence of the initial education or any yearly education regarding the PICC line medication administration for the facility or agency LPN's working in the facility. The DON confirmed the nurse administering the medications are to sign the MAR indicating the medication was administered. There was no evidence The LPN (who has completed the Board certified educational program) attends a yearly in-service of administration of intravenous fluids and medications. 28 Pa. Code 201.20(a) Staff Development. 28 Pa Code 211.12(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 8 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and staff interviews, it was determined the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 16 residents reviewed (Residents 51). Residents Affected - Few Findings include: According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. Review of Resident 51's clinical record revealed admission to the facility on October 3, 2020, with diagnoses that included chronic obstructive pulmonary disease (COPD-type of obstructive lung disease characterized by long-term poor airflow. The main symptoms include shortness of breath and cough with sputum production). Review of facility investigative documentation dated August 24, 2024, indicated the resident had an unwitnessed fall, the resident was assessed without injury. Review of resident 51's nursing progress notes revealed a noted dated August 27, 2024, that Resident 51 had told the nurse on duty, an LPN, (licensed practical nurse) that his right hand was hurting him. The nurse noted the resident's hand was reddened and indicated she would inform the nursing supervisor. Review of the resident's clinical record during survey ending September 6, 2024, revealed no documented evidence that any further follow up or nursing assessment was completed until brought to the attention of the facility on September 6, 2024. Further review of the resident's clinical record revealed the resident received Tylenol 325 mg two tablets for mild pain three times between August 27, 2024, and September 5, 2024. Resident 51's record revealed on September 6, 2024, an X-ray was completed of the resident's right hand and no injury was noted. There was no documented evidence the facility staff timely assessed the resident's right hand after complaint of pain following a fall. An interview with the Nursing Home Administrator, and the Director of Nursing on September 6, 2024, at 11:10 AM, confirmed the facility failed to timely assess the resident's right hand after a fall and residents complaint of pain. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 9 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, select facility policy review and staff interview it was determined the facility failed to maintain an environment free of potential accident hazards during medication administration on one of two resident care units. (second floor) for one of two residents observed. Findings include: A review of facility policy entitled Medication Administration, provided by the facility on September 6, 2024, indicated the nurse preparing the medication for administration is to observe resident consumption of medication. An observation on the second floor on September 6, 2024, at 9:26 a.m. during observation of medication administration revealed there were medications located on overbed table in room [ROOM NUMBER]. Two white tablets were observed in a clear plastic medication cup on Resident 32's overbed table. During an interview with Resident 32, who resides in room [ROOM NUMBER] on September 6, 2024, at 9:27 a.m. the resident stated the nurse left the medications on his table for him to take during breakfast, but he didn't want to take them. Review of Resident 32's Medication Administration Record (MAR) dated September 2024, revealed the resident was scheduled to receive Amlodipine Besylate 10mg for hypertension, and Meloxicam (nonsteroidal anti-inflammatory) 15 mg for spinal stenosis (narrowing of the spine), daily at 9:00 a.m. Interview with Employee 2, licensed practical nurse (LPN), on September 6, 2024, at 9:28 a.m. confirmed she left the medications at Resident 32's bedside. Employee 2 further stated she leaves the resident's medications scheduled to be taken with breakfast and will she will observe the resident fro the hallway to ensure he consumed his medications. Employee 2 confirmed that resident medications were not to be left at the bedside, and the nurse is to observe each resident take their medications. During an interview with the Director of Nursing (DON) on September 6, 2024, at approximately 1:40 PM confirmed the medications should not have been left at the bedside and created a potential accident hazard if accidently injected by another resident. 28 Pa. Code 211.9 (a)(1) Pharmacy services. 28 Pa Code 211.12 (c)(d)(5) Nursing services 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 10 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policy, and clinical records, and staff interview, it was determined the facility failed to thoroughly assess and evaluate bowel function and implement individualized approaches to restore normal bowel function to the extent possible for one out of 6 sampled residents (Resident A2). Findings include: A review of the facility policy for incontinence management reviewed September 30, 2024 revealed, the facility will assess residents for their continence status, potential contributing factors and if incontinent, provide interventions to attempt to maintain or attain their highest level of continence. The procedure includes: A resident's continence status will be assessed within 2 weeks of admission, routinely and upon significant change in continence status, If a resident is incontinent, the type of continence will be determined if able, Interventions and treatment will be provided to help residents restore or improve bowel and or bladder function and prevent urinary tract infections to the extent possible. A review of the clinical record revealed that Resident A 2 was admitted to the facility on [DATE], with diagnoses to include, dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and atrial fibrillation (an abnormal heartbeat). A review of a significant change MDS, Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 31, 2024 indicated the resident was frequently incontinent of bowel. A review of Resident A 2'S quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was always incontinent of bowel. A review of the resident's plan of care dated August 23, 2024 revealed that the resident is incontinent of bowel at times. The residents plan of care dated October 17, 2024 revealed that the resident is incontinent of bowel. Planned interventions to include, assist resident to toilet as needed and identify an incontinence pattern and establish a toileting plan accordingly. A review of toileting records dated October 13, 2024 through November 1, 2024 (past 18 days) indicted the resident was noted to be continent on one of the days and incontinent of bowel on the remaining days. The facility failed to initiate a three day bowel activity assessment in order to determine the resident's pattern of incontinence in response to the documented resident's decline in bowel function. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 11 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further, the facility failed to identify the resident's habits or patterns of incontinence to develop an individualized toileting plan to restore bowel function to the extent possible for the resident. Interview with the Director of Nursing on November 1, 2024, at approximately 6:00 PM confirmed the facility failed to thoroughly assess the resident's bowel and bladder function to identify the resident's habits, patterns and develop a plan to meet the residents' toileting needs to decrease incontinence to the extent possible. 28 Pa. Code 211.12 (d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 12 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy and staff interview, it was determined the facility failed to timely respond to a resident's increased level of pain and provide an effective pain management to alleviate pain for four residents of 18 residents sampled (Residents 17, 3, 41, and 18). Residents Affected - Some Findings include: Review of facility policy entitled Pain Management (no date indicated as when it was last reviewed) provided by the facility on September 5, 2024, revealed based upon the evaluation, the facility, in collaboration with the attending physician/prescriber, other health care professionals, and the resident and /or resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain beginning on admission. For residents with an addiction history or opioid use disorder, the facility should use strategies to relieve pain while also considering opioid use addiction history. These strategies may include continuation of medication assisted treatment, if appropriate, non-opioid pain medications, and non-pharmacological approaches. A review of Resident 17's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic pain, panic disorder, and major depressive disorder. A review of Resident 17's physician's orders dated July 5, 2024, revealed an order for Tramadol HCL (an opioid pain medication) 50 mg tablet mouth every 8 hours as needed for moderate to severe pain. A review of Resident 17's Medication Administration Record (MAR) dated July 2024, revealed the Tramadol, was administered on thirty-eight occasions for the month of July without any documented evidence that licensed nursing staff attempted non-pharmacological interventions prior to its administration. A review of Resident 17's August 2024 MAR revealed the Tramadol was administered on thirty-eight occasions for the month of August without any documented evidence that licensed nursing staff attempted non-pharmacological interventions prior to administration. A review of Resident 3's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included chronic pressure ulcer (wound caused by increased pressure to an area on the body) to the sacrum and right heel and peripheral vascular disease (PVD - is a condition that narrows blood vessels away from the heart or brain, causing pain and discomfort in the arms and legs). A review of Resident 3's physician's orders dated July 15, 2024, revealed an order for Hydrocodone-Acetaminophen (an opioid pain medication) 5-325 tablet give 2 tablets by mouth every 8 hours as needed (PRN) for Pain Scale 1-5. A review of Resident 3's Medication Administration Record dated July 15, 2024, through August 2024, revealed the Hydrocodone-Acetaminophen was administered outside of the prescriber's orders on the following dates and times: July 23, 2024, at 12:17 p.m., for a reported pain level of 8 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 13 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0697 July 24, 2024, at 8:52 a.m., for a reported pain level of 7 Level of Harm - Minimal harm or potential for actual harm August 1, 2024, at 6:46 a.m., for a reported pain level of 7 August 4, 2024, at 7:32 a.m., for a reported pain level of 8 Residents Affected - Some August 4, 2025, at 5:53 p.m., for a reported pain level of 8 August 6, 2024, at 9:16 a.m., for a reported pain level of 8 August 7, 2024, at 8:23 a.m., for a reported pain level of 8 August 8, 2024, at 4:44 a.m., for a reported pain level of 8 August 9, 2024, at 8:25 a.m., for a reported pain level of 8 August 10, 2024, at 7:55 a.m., for a reported pain level of 7 August 12, 2024, at 2:11 a.m., for a reported pain level of 7 August 13, 2024, at 5:30 p.m., for a reported pain level of 7 August 15, 2024, at 9:57 a.m., for a reported pain level of 7 August 17, 2024, at 11:01 p.m., for a reported pain level of 9 August 18, 2024, at 6:07 p.m., for a reported pain level of 6 August 20, 2024, at 6:11 a.m., for a reported pain level of 7 August 21, 2024, at 8:54 a.m., for a reported pain level of 8 August 23, 2024, at 5:23 p.m., for a reported pain level of 8 August 24, 2024, at 9:07 a.m., for a reported pain level of 8 August 25, 2024, at 12:13 p.m., for a reported pain level of 8 August 27, 2024, at 3:57 a.m., for a reported pain level of 7 August 27, 2024, at 12:26 p.m., for a reported pain level of 8 August 31, 2024, at 3:54 a.m., for a reported pain level of 8 Further review of Resident 3's clinical record revealed licensed nursing staff failed to attempt non-pharmacological interventions prior to administering the resident's Hydrocodone-Acetaminophen as indicated above. A review of Resident 41's clinical record revealed that the resident was admitted to the facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 14 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on [DATE], with diagnoses that included chronic pressure ulcers to the sacrum, right buttocks, and left buttocks (stage 3-4) and paraplegia (is a form of paralysis that affects the legs due to damage to the brain or spinal cord). A review of Resident 41's physician's orders dated July 15, 2024, revealed an order for Oxycodone HCl (narcotic medication) 5 mg give 2 capsules by mouth every 8 hours as needed for moderate to severe pain (7-10). A review of Resident 41's MAR dated July 15, 2024, through August 2024, revealed the resident's Oxycodone was administered outside of the prescriber's orders on the following dates and times: July 19, 2024, at 1:43 a.m., for a reported pain level of 5 July 29, 2024, at 5:49 a.m., for a reported pain level of 5 August 8, 2024, at 2:28 a.m., for a reported pain level of 6 August 18, 2024, at 6:15 p.m., for a reported pain level of 6 August 21, 2024, at 6:58 a.m., for a reported pain level of 4 August 26, 2024, at 8:32 a.m., for a reported pain level of 5 A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses, which included type 2 diabetes, hypertension (high blood pressure), and history of falls with fractures. A review of Resident 18's physician orders revealed an order dated August 2, 2024, for Oxycodone HCL 5mg every 12 hours as needed for pain for 14 days. The order was revised on August 7, 2024, to discontinue the order for Oxycodone 5mg every 12 hours as needed for pain and a new order for Oxycodone 5mg every 8 hours as needed for pain was noted. Further review of Resident 18's physician orders revealed an order dated August 14, 2024, to discontinue the order for Oxycodone 5mg every 8 hours as needed for pain and a new order for Oxycodone 5mg every 6 hours as needed for pain was noted. A review of Resident 18's August 2024 MAR revealed that Oxycodone was administered 35 times for the month of August. Further licensed nursing staff failed to attempt non-pharmacological interventions prior to administering the resident's pain medication. An interview with the Director of Nursing on September 6, 2024, at 11:35 a.m., confirmed the facility failed to provide non-pharmacological interventions and proved ineffective prior to administration of a as needed pain medication and failed to follow physician's orders for administration of pain medication. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 15 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation and staff interview, it was determined the facility failed to correctly post nurse staffing information. Residents Affected - Many Findings include: During an observation on September 4, 2024, at approximately 8:15 AM the facility's current posted nursing hours were dated August 29, 2024. Further observation revealed that the posted nursing time dated August 29, 2024, was not completed for each shift. The facility failed to post the daily nurse staffing data as required. The facility failed to post the nursing time on a daily basis and failed to include the required information. 28 Pa. Code 201.18 (b)(3) Management 28 Pa. Code 211.12 (d)(1)(3)(4) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 16 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, observations and staff interviews it was determined that the facility failed to provide pharmacy services, routine drugs and pharmaceuticals, to ensure timely medication administration as prescribed for one resident out of 18 sampled (Resident 180) and maintain accurate narcotic administration records for one resident out of 18 sampled (Resident 18). Findings include: A review of the clinical record revealed that Resident 180 was admitted to the facility on [DATE], with diagnoses, which included human immunodeficiency virus (HIV), Type 2 diabetes, and Alzheimer's disease. Resident 180 had admission physician orders for Miralax oral powder 17 GM/scoop one scoop daily for constipation, Mirtazapine 15mg daily for depression, Symtuza (Darunavir-Cobicistat-Emtricitabine-Tenofovir Alafenamide) daily for HIV, Tamsulosin HCL 0.4mg daily for BPH (benign prostatic hyperplasia), Zyprexa 2.5mg daily for psychosis, and Namenda 10mg twice a day for Alzheimer's disease. During observation of medication administration for Resident 180 on September 6, 2024, at 9:15 a.m. with Employee 2, licensed practical nurse, the resident's Symtuza medication was not available in medication cart for administration. A review of Resident 180's Medication Administration Record (MAR) dated September 2024, revealed that the medication was last administered on September 4, 2024, at 9:00 a.m. There was no evidence that the medication was administered on September 5, 2024, at 9:00 a.m. An interview with Employee 1 (LPN), on September 6, 2024, at 9:30 a.m. revealed that the medication was not available for administration on September 5, 2024, at 9:00 a.m., and that Employee 1 had made the Director of Nursing (DON) aware. During an interview with the Director of Nursing on September 6, 2024, at approximately 10:00 a.m. she confirmed that the medication was not available from pharmacy. According to the DON's phone conversation with pharmacy on September 6, 2024, at approximately 10:15 a.m., the resident's payer source was questioned by pharmacy and an email was sent to the DON to get approval to dispense the medication. The DON stated that she did not receive the email and confirmed that the resident had not received the medication since admission on [DATE], a total of 3 days. A review of Resident 180's clinical record failed to provide evidence that the resident's representative or the resident's physician was made aware that the medication to treat HIV was not available from pharmacy and was not administered as ordered. Interview with the DON on September 6, 2024, at approximately 11:00 a.m., confirmed that the facility failed to ensure availability of and provide prescribed medications for Resident 180. The DON further confirmed that documentation on September 4, 2024, at 9:00 a.m. that the Symtuza was administered was not accurate due to medication not being available from pharmacy and that the facility failed to notify the resident's representative and physician. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 17 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of the clinical record revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses, which included type 2 diabetes, hypertension (high blood pressure), and history of falls with fractures. An interview conducted with Resident 18 on September 4, 2024, at approximately 10 a.m. revealed that the resident had concerns about the administration of her prn (as needed) narcotic pain medications. According to Resident 18, there was a day that the facility ran out of her pain medication, and the resident stated that someone took what pills were left. The resident felt that her medication had been stolen. A review of Resident 18's physician orders revealed an order dated August 2, 2024, for Oxycodone HCL 5mg every 12 hours as needed for pain for 14 days. The order was revised on August 7, 2024, to discontinue the order for Oxycodone 5mg every 12 hours as needed for pain and a new order for Oxycodone 5mg every 8 hours as needed for pain was noted. Further review of Resident 18's physician orders revealed an order dated August 14, 2024, to discontinue the order for Oxycodone 5mg every 8 hours as needed for pain and a new order for Oxycodone 5mg every 6 hours as needed for pain was noted. A review of the resident's controlled substance records accounting for the above narcotic medication revealed on the following dates the nursing staff signed out a dose of the resident's supply of Oxycodone 5 mg. August 4, 2024, at 11:00 a.m. August 7, 2024, at 2:20 p.m. August 9, 2024, at 3:30 a.m. August 10, 2024, at 8:40 a.m. August 11, 2024, at 8:00 a.m. August 11, 2024, at 5:00 p.m. August 12, 2024, at 8:00 p.m. August 14, 2024, at 8:00 a.m. August 14, 2024, at 5:00 p.m. August 15, 2024, at 12:00 p.m. August 18, 2024, at 9:35 a.m. August 19, 2024, at 10:30 p.m. August 20, 2024, at 9:00 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 18 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0755 August 22, 2024, at 7:10 p.m. Level of Harm - Minimal harm or potential for actual harm August 23, 2024, at 9:00 a.m. August 24, 2024, at 9:00 a.m. Residents Affected - Few August 25, 2024, at 12:00 p.m. August 26, 2024, at 10:00 a.m. August 26, 2024, at 8:00 p.m. August 27, 2024, at 8:00 p.m. August 28, 2024, at 9:00 a.m. August 30, 2024, no time indicated August 31, 2024, at 8:06 a.m. September 1, 2024, at 4:30 p.m. However, the administration of the controlled drug to the resident was not recorded on the resident's Medication Administration Record on those dates and times. There was no evidence that Resident 18's medication had been stolen as initially stated by resident. An interview on September 6, 2024, at approximately 1:40 p.m. the Director of Nursing confirmed the inconsistencies in the accounting and administration of the opioid pain medications for Resident 18. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa Code 211.9 (a)(1)(c)(2)(4)(k) Pharmacy services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 19 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview, it was determined the facility failed to ensure adherence to medication expiration/use by dates on two of four medication carts (Second Floor - Long hall and Short hall). Findings include: Observation of the medication cart on Second Floor identified as the Long Hall cart, on September 5, 2024, at 11:27 a.m., in the presence of Employee 1, Licensed Practical Nurse (LPN) revealed one multidose vial of Humalog insulin opened and not dated to when it was opened, and one multidose vial of Humalog insulin not opened or dated and labeled refrigerate. Interview with Employee 1, LPN revealed that multidose vials of Humalog insulin should be discarded 28 days after being opened and dated when opened. Employee 1, LPN further confirmed that unopened multidose insulin should remain refrigerated until needed. Observation of an additional medication cart on the Second floor (short hall) on September 5, 2024, at approximately 11:45 a.m. revealed a Novolog insulin pen that was opened and not dated. Further review of the cart revealed an opened and undated bottle of Simbrinza eye drops, and an opened undated bottle of Latanoprost eye drops. According to manufacturer instructions, Simbrinza eye drops should not be used more than 125 days after opening the bottle, and Latanoprost eye drops should be discarded 6 weeks after being opened. Employee 1 confirmed during observation of the Short Hall medication cart, that the insulin pen and eye drops were to be dated when opened. During an interview with the DON (Director of Nursing) on September 6, 2024, at approximately 1:00 PM it was confirmed that the multidose vials of insulin and eye drops should have been dated when opened to determine expiration/use by date. 28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 20 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observations, resident and staff interview, and test tray results, it was determined the facility failed to serve meals that are palatable, attractive, and at safe and appetizing temperature for two of the 18 residents sampled (Resident 44 and 6) and including experiences reported by 4 out of four residents during a group interview (Residents 46, 57, 16, and 35). Residents Affected - Some Findings include: According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of Danger Zone, found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness. During a group resident council meeting conducted with four cognitively intact residents revealed at times the meals were not consistently served at palatable temperatures. An interview with Resident 44, a cognitively intact resident, on September 4, 2024, at 10:30 a.m., revealed the facility's food was served cold most times and that the food was not palatable. A review of the facility's posted menu for Thursday, September 5, 2024, was popcorn chicken, potato wedges, creamy cole slaw, and gelatin. During the lunch meal observations on Unit 3 on September 5, 2024, at 12:50 p.m., observed the first meal cart arrived on the unit and staff did not begin to initiate the lunch tray service until 1:03 p.m. A test tray was performed with Resident 3's lunch tray on September 5, 2024, at 1:09 p.m., revealed the resident's tray card (helps manage resident nutritional profiles to ensure that food placed on the tray corresponds to the diet ordered) consistent carbohydrate and no added salt (CCHO NAS a therapeutic diet that provides a consistent and balanced amount of carbohydrates to manage blood glucose levels of diabetics and limits added salt for individuals with cardiovascular conditions) diet, regular texture, thin consistency. Additionally, the tray card noted that the resident required built up utensils an inner lip plate. Results of the test tray as follows; popcorn chicken (received 6-pieces) 98 degrees Fahrenheit, potato wedges (4 pieces) 108.5 degrees Fahrenheit, cole slaw 54.5 degrees Fahrenheit, lime gelatin - 54.1 degrees Fahrenheit, and milk 46.9 degrees Fahrenheit. The food on the plate was sparse and unappealing. All main meal items were white colored and bland. The built-up fork's prongs were bent. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 21 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Additionally observed, the staff passing the meals ran out of mugs for hot beverages and clear plastic cups for cold beverages. Staff reported that dietary should send enough cups for hot and cold beverages for each meal, but often they had to substitute with disposable cups to timely serve the meals. An interview with Resident 6 on September 5, 2024, at 1:30 p.m., revealed he refused his meal tray and reported the meal was bland, cold, and not enough food for him and that he always had to request something else when this particular meal was served. A review of a facility policy entitled Nutrition Services that was provided by the facility on September 6, 2024, at 11:15 a.m., indicated the facility would provide meals for each resident, with preferences accommodated, timely meal services, and assist with eating as needed. To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41 degrees Fahrenheit to 135 degrees Fahrenheit) will be kept to a minimum. Foods left out without a source of heat (for hot foods), or refrigeration (for cold foods) longer than two hours will be discarded. The facility failed to provide meals that were visually appealing and met resident preferences and palatability and failed to ensure timely meal delivery that resulted in unpalatable food temperatures. During an interview with the food service manager on September 6, 2024, at 11:30 a.m., confirmed that meals should be visually appealing, served timely, palatable and served at safe and appetizing temperatures food temperatures to meet resident's preferences. 28 Pa. Code: 211.6 (f) Dietary Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 22 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the facility's planned cycle menu, observation and staff and resident interviews it was determined that the facility failed to provide therapeutic diets prescribed by resident's attending physician for two residents out of 18 sampled (Resident 3 and 44). Findings include: A review of a facility policy entitled Therapeutic Diets provided by the facility on September 5, 2024, indicated that the facility provides therapeutic diets per need and resident preference. Therapeutic diets are prescribed by the Physician or Dietitian and used to balance medical needs of the resident with their preferences. A review of the facility's approved diet manual (serves as a guide in prescribing diets, and an aid in planning regular and therapeutic diet menus, and as a reference for developing recipes and preparing diets) dated June 2015, indicated that the facility's carbohydrate consistent diet/consistent carbohydrate diet was used to help diabetic resident manage blood glucose levels. The diet provides three meals and one bedtime snack daily and carbohydrate servings are equally distributed across breakfast, lunch, and dinner (75 - 105 grams per meal), with a smaller amount provided at the bedtime snack (25-30 grams per snack). A review of Resident 44's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included type two diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar (glucose) as a fuel and the long-term condition results in too much sugar circulating in the blood that may lead to disorders of the circulatory, nervous and immune systems) and diabetic foot ulcer (is a debilitating and severe manifestation of uncontrolled and prolonged diabetes that presents as ulceration, usually located on the plantar aspect of the foot), and was cognitively intact. A review of Resident 44's physician's orders dated October 21, 2019, at 11:18 a.m., revealed that the resident was ordered a Consistent Carbohydrate Diet with regular texture. During an interview with Resident 44 on September 4, 2024, at 10:15 a.m., revealed that he was supposed to follow a diabetic diet and that the facility does not offer residents a diabetic diet. He reported most of the meals served are all carbs. During meal round observations September 5, 2024, at 12:50 p.m., revealed that the planned meal was popcorn chicken, potato wedges, creamy [NAME] slaw, and gelatin. An observation of Resident 3's lunch tray on September 5, 2024, at the time of meal round observation above revealed his tray card indicated that he was ordered a consistent carbohydrate and no added salt (CCHO NAS a therapeutic diet that provides a consistent and balanced amount of carbohydrates to manage blood glucose levels of diabetics and limits added salt for individuals with cardiovascular conditions) diet, regular texture, thin consistency. Further Resident 3's provided diabetic meal consisted of six popcorn chicken bites, four potato wedges, half cup of creamy [NAME] slaw, and lime gelatin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 23 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An observation of Resident 44's lunch tray on September 5, 2024, revealed the resident was served the same diabetic meal as Resident 3. A review of the facility's four-week Spring/Summer 2024 menu cycle that was approved by the Registered Dietitian (RD) Consultant on June 19, 2024, revealed that throughout the meal cycle therapeutic spread sheet for the facility's consistent carbohydrate or low concentrated sweet diet were marked with an x. During an interview with the facility's RD consultant on September 6, 2024, at 10:00 a.m., revealed that the facility's regular diet was adapted to adhere to physician prescribed therapeutic diets. However, the RD consultant was not able to provide a nutrient analysis (is the description of the method used to determine the amounts of these nutrients in a food and used to assess the nutritional adequacy in menu planning) for a consistent carbohydrate diet/diabetic diet. Additionally, the RD consultant indicated that the x noted on the therapeutic spread sheet indicated that the planned meal wasn't included for that meal and confirmed that the facility did not offer a consistent carbohydrate diet/diabetic diet to accommodate diabetic resident's needs. An interview with the facility's food service manager on September 6, 2024, at 10:25 a.m., confirmed that the planned meals served for lunch on September 5, 2024, was mostly starchy, high carbohydrate foods and lacked sufficient protein, and confirmed that the regular menu was used for the consistent carbohydrate diets. 28 Pa. Code 211.12 (d)(3)(5) Nursing services 28 Pa. Code 211.6 (a) Dietary services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 24 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review clinical record, facility provided documents, the facility's plan of correction from the surveys ending on August 9, 2024, and on September 6, 2024, and the outcome of the activities of the facility's quality assurance committee it was determined the facility failed to develop and implement a quality assurance plan, which was able to identify, and correct ongoing quality deficiencies related to the assessment and implementation of bowel and bladder programs for one of 6 residents sampled (Resident A2). Findings included: During survey ending August 9, 2024 deficient facility practice was identified related to the facility's failure to assess and implement a program to maintain or restore this same resident's bowel function. The facility developed a plan of correction that included, The bowel and bladder documentation will be assumed by the nursing staff. The documentation will be audited daily by the nursing supervisor to ensure completion. The nursing staff will be educated on the new process for managing the facility bowel and bladder program. The bowel and bladder programs will be audited weekly for 4 weeks and then monthly to ensure the deficient practice does not recur. A review of the clinical record revealed that Resident A2 was admitted to the facility on [DATE], with diagnoses to include, dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and atrial fibrillation (an abnormal heartbeat). A review of Resident A 2's quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was always incontinent of bowel. A review of the resident's plan of care dated August 23, 2024 revealed the resident is incontinent of bowel at times. The residents plan of care dated October 17, 2024 revealed that the resident is incontinent of bowel. Planned interventions to include, assist resident to toilet as needed and identify an incontinence pattern and establish a toileting plan accordingly. A review of toileting records dated October 13, 2024 through November 1, 2024 (past 18 days) indicted the resident was noted to be continent on one of the days and incontinent of bowel on the remaining days. The facility failed to initiate a three day bowel activity assessment in order to determine the resident's pattern of incontinence in response to the documented resident's decline in bowel function. Further, the facility failed to identify the resident's habits or patterns of incontinence to develop an individualized toileting plan to restore bowel function to the extent possible for the resident. The facility's QAPI committee failed to identify the facility's corrective action plan was not developed and/or implemented in a manner consistent with the regulatory guidelines for the deficiency cited, to ensure that solutions to the problem was sustained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 25 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0867 Cross refer F690 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12 (d)(1)(5) Nursing Services. 28 Pa. Code 201.18 (e)(1)(3) Management. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 26 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of facility QAPI meeting attendance records and staff interviews, it was determined the facility failed to ensure that the required committee members met at least quarterly for one quarter out of three reviewed. Residents Affected - Some Findings include: An interview was conducted with the Nursing Home Administrator (NHA) on September 6, 2024, at approximately 11:30 AM, revealed that facility's QA/QAPI committee members included the NHA, Director of Nursing (DON), Medical Director, and department heads. The NHA reported that the committee meets at least quarterly. Review of the facility's QA/QAPI committee attendance sheets revealed the committee met in April 2024 and July 2024. Further review of the QA/QAPI committee attendance sheets revealed there was no documented evidence the Medical Director attended the meeting held July 2024. Interview with the NHA on September 6, 2024, at approximately 11:35 AM, confirmed the facility's QA/QAPI committee failed to provide documented evidence that the facility's Medical Director consistently attended/participated in the meetings at least quarterly. 28 Pa. Code 201.18(e)(1)(2)(3) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 27 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on a review of select facility policy, review of Center for Medicare and Medicaid services memo, a review of ASHRAE guidelines for Legionella, review of facility documentation, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for twelve of twelve months (August 2023 through August 2024). Residents Affected - Some Findings Include: Review of Department of Health and Human services, Centers for Medicare and Medicaid services (CMS) memo Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated July 6, 2018, revealed facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water. This policy memorandum applies to Hospitals, Critical Access Hospitals, and Long-Term Care. Facilities must have water management plans and documentation that, at a minimum, ensure each facility conducts a facility risk assessment to identify where Legionella could grow and spread in the facility water system. Facilities must develop and implement a water management program that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard and the CDC toolkit. Facilities must specify testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained. Review of the ASHRAE guidance Managing the Risk of Legionellosis Associated with Building Water Systems dated December 2020, indicated the most commonly used supplemental disinfection methods are treatment with chlorine, chlorine dioxide, copper -silver ions, and monochloramine. The guidance further indicated the recommended levels of residual chlorine are 0.50 - 3.00 ppm (parts per million). Review of the facility provided water management information failed to include specific testing protocols and acceptable ranges for control measures along with a description of the facility's water system using a flow diagram. Review of the Water Management Program Control Measures did not contain a log for Point of Use Disinfectant (the level of chlorine concentration in the water) indicated to measure and record hot water and cold water chlorine concentration as point of use, and to note that chlorine concentration below 0.5 ppm and above 4.0 ppm as outside the control limits. During an interview on September 6, 2024, at approximately 11:40 a.m. the Director of Nursing confirmed that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility. 28 Pa. code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b) (1) (e) (1) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 28 of 29 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 395273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Scranton 824 Adams Avenue Scranton, PA 18510 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)

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on review of regulations, facility policy review, and staff interviews, it was determined that the facility failed to have an Infection Preventionist (IP) that worked at least part time at the facility. Residents Affected - Some Findings Include: The Centers for Medicare and Medicaid Services regulation §483.80(b)(3) states the facility must designate one or more individuals as the infection preventionist who are responsible for the facility's Infection Prevention and Control Program. The IP must work at least part-time at the facility, physically work onsite in the facility, cannot be an off-site consultant, or perform the IP work at a separate location. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on September 5, 2024, at 11:40 AM, they stated that the prior IP left the role in the beginning of August 2024, and there was currently no designated IP. Further they stated the facility has hired two new Registered Nurses, but neither had completed the required IP training. In an interview on September 6, 2024, at 9:47 a.m., the Director of Nursing confirmed that the facility had no staff that were credentialed infection preventionists. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395273 If continuation sheet Page 29 of 29