Inspection·January 30, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Interview with Resident 56 on January 30, 2025, at 11:35 AM stated that her food orders were frequently incorrect. She provided an example of ordering a grilled cheese sandwich but receiving a hamburger stating, That's all they have cause the truck never came. She continued, I don't get my coffee. They say the ran out of coffee cause the truck didn't come Residents Affected - Many Review of Resident Council Meeting Minutes (January 14, 2025): The minutes documented the alternate menu was not always available, and basic food supplies such as sugar, butter, milk, tea, ketchup, and coffee were frequently out of stock. It was noted that the facility was experiencing food supply shortages, but there was no documented evidence that these concerns were addressed by the facility. The facility frequently runs out of bread At the time of the survey ending January 30, 2025, there was no documented evidence that the facility addressed the concerns voiced during the food committee meeting regarding food supply shortages. Review of the facility's Week 3 lunch menu for Thursday January 30, 2025, revealed that the planned menu included maple glazed ham, macaroni and cheese, Prince [NAME] vegetable blend, wheat dinner roll and choice of dessert. However, an observation of the lunch meal on Thursday January 30, 2025, at 12:34 PM revealed chicken and dumplings were severed in place of the ham and macaroni and cheese, and mixed vegetables was served in place of the planned Prince [NAME] vegetable blend. Interview with the dietary manager at this time confirmed substitutions for the lunch meal were made. The dietary manager noted the facility maintains a substitution log and frequently substitutions are made due to not having the food items needed based on the planned menu. Review of the facility's meal substitution records revealed multiple instances due to unavailable ingredients affecting a variety of planned menu items. Review of the facility's Substitution Record for November 2024 revealed that planned menu items such as baked potatoes, BBQ beef, spinach, mixed vegetables, California blend vegetables, coleslaw, rice, and potato chips all required substitutions due to the items/ingredients to prepare the food items not being available in the facility. Review of the facility's Substitution Record for December 2024 revealed that planned menu items such as taco coup, stuffed shells, chicken casserole, tossed salad, hot dogs, and Prince [NAME] vegetable blend all required substitutions due to the items/ingredients to prepare the food items not being available in the facility. Review of the facility's Substitution Record for January 2025 revealed that planned menu items such as ham salad, peaches, pears, hot dogs, French toast, bacon, fruit cocktail, egg salad, taco soup, fish, maple ham, Prince [NAME] vegetable blend, and macaroni and cheese all required substitutions due to the items/ingredients to prepare the food items not being available in the facility. An interview with the Nursing Home Administrator (NHA) and the Dietary Manager on January 30, 2025, at approximately 1:20 PM confirmed that the facility was unable to consistently follow the written planned menus due to supply shortages. The Dietary Manager stated that menu items were ordered timely, but the food service supplier was not delivering the food order in its entirety. The NHA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 2 of 5 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 395456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Wyoming Valley 50 N. Pennsylvania Ave. Wilkes Barre, PA 18701 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 0803 Level of Harm - Minimal harm or potential for actual harm confirmed that the facility's food service supplier is not providing the facility with their full order upon delivery. The facility to follow written planned menus as required which resulted in unapproved meal substitutions, lack of access to resident-preferred menu options, and inconsistent meal service. Residents Affected - Many 28 Pa. Code 211.6(a) Dietary Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 3 of 5 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 395456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Wyoming Valley 50 N. Pennsylvania Ave. Wilkes Barre, PA 18701 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 observation, review of food committee minutes, resident and staff interviews, and test tray results, it was determined the facility failed to serve meals that were palatable and at a safe and appetizing temperature for four of the 7 residents sampled (Residents 1, 56, 14, and 87) Residents Affected - Some Findings include: According to the federal regulatory guidance at 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. Review of the Resident Food Committee Meeting minutes dated December 11, 2024, revealed the residents were asked if the temperature of the hot/cold foods were appropriate. The response indicated was no, with the added comment: cold meals at dinner. Review of the Resident Food Committee Meeting minutes dated January 15, 2025, revealed the residents were asked if the temperature of the hot/cold foods were appropriate. The response indicated was no with the comment not always and specifically noting French fries. During an interview with Resident 14 on January 30, 2025, at 10:00 AM, reported were served at best, lukewarm and that French fries were never hot. He stated he had voiced concerns in Food Committee Meetings, but the facility failed to address the issue. During an interview with Resident 1 on January 30, 2025, at 10:47 AM, she reported that the hot food was frequently cold, sometimes warm on the outside but cold in the middle. She reported sending food back to the kitchen out of concern for food safety. During an interview with Resident 87 on January 30, 2025, at 11:00 AM, reported the hot food was never hot, just warm. During an interview with Resident 56 on January 30, 2025, at 11:10 AM, she reported that hot food was cold sometimes, but she has gotten used to the food not being served hot, so she eats it anyway. A test tray performed on the 2nd floor Nursing Unit on January 30, 2025, revealed the test tray arrived on the Nursing Unit at 12:17 PM. The hot meal was chicken and dumplings, mixed vegetables, a butterscotch bar, and a beverage of choice. At 12:34 PM, upon serving the last resident, a test tray evaluation was conducted with the Dietary Manager present. The food temperatures were recorded as follows: Chicken and dumplings: 125.5 degrees Fahrenheit below the 135 degrees Fahrenheit minimum for hot foods Mixed vegetables: 104.8 degrees Fahrenheit significantly below the required temperature The hot food tasted cold and was not palatable at the time it was served. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 4 of 5 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 395456 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Wyoming Valley 50 N. Pennsylvania Ave. Wilkes Barre, PA 18701 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 An interview with the Dietary Manager on January 30, 2025, at 12:36 PM confirmed that food must be palatable and served at safe and appetizing temperatures. During an interview on January 30, 2025, at approximately 1:10 PM, the Nursing Home Administrator verified the facility is responsible for ensuring that all residents receive meals that are palatable and at a safe and appetizing temperature. The facility failed to serve food at proper temperatures and resulted in the lack of palatable and appetizing meals with the potential of food safety risks and unaddressed resident concerns, which compromised the quality of the dining services provided by the facility. 28 Pa. Code 201.18 (e)(3)(4) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 5 of 5