Health inspection·March 14, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm An observation on March 13, 2025, at 10:27 AM in resident room [ROOM NUMBER] revealed the windows were cloudy, reducing visibility. Interview with Resident 48, at the time of the observation, revealed she has been in room [ROOM NUMBER] for over two years and has never observed anyone cleaning the windows. She stated she loves tending to her plants in her room and on the windowsill and enjoys looking outside, but the windows are so dirty, it kind of ruins the atmosphere. Residents Affected - Some An observation on March 13, 2025, at 10:40 AM in resident room [ROOM NUMBER] revealed the windows were cloudy, reducing visibility. Interview with Resident 17, during the time of the observation, the resident stated I keep telling them they need to clean them. How am I supposed to see the cute guys outside? An observation on March 13, 2025, at 10:48 AM in resident room [ROOM NUMBER] revealed the windows were cloudy, reducing visibility. Interview with Resident 7, at the time of the observation, revealed I sit in my room all day and I can't even see out the windows because they're dirty. Interview with the Nursing Home Administrator and Director of Nursing on March 14, 2025 at approximately 11:00 PM confirmed the facility's environment should be kept in good repair and maintained in a clean and homelike manner. 28 Pa Code 201.18(e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 2 of 20 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 03/14/2025 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records and select facility policy, and staff interview, it was determined the facility failed to ensure the evaluation of a resident's need and use of physical restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom, and failed to obtain informed consent prior to the use of the physical restraint for one of one sampled resident with restraints (Resident 1). Residents Affected - Some Findings included: A review of the facility's policy titled Restraint Free Environment last reviewed by the facility February 19, 2025, revealed that physical restraint refers to any method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include but are not limited to: Applying leg or arm restraints, hand mitts, soft ties, or vests that the resident cannot remove. Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents the resident from rising. Further review of the policy provided by the facility revealed that a physician's order alone is not sufficient to warrant the use of physical restraint. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints. Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions to address any risks related to the use of the restraint. Review of the facility's policy titled Use of Restraints: last reviewed by the facility February 19, 2025, further indicated that restraints shall only be used upon written order of a physician and after obtaining consent from the resident and/or representative. The order shall include the following: (a) the specific reason for the restraint(as it relates to the resident's medical symptom); (b) how the restraint will be used to benefit the resident's medical symptoms; (c) the type of restraint, and the period of time for the use of the restraint. Observation of Resident 1 on March 13, 2025, at 11:45 AM in the dining room, revealed the resident was seated in a specialty wheelchair, in a tilted position. The resident was observed to be wearing a chest harness (provides a rearward pull to the shoulders to prevent a forward posture), a wheelchair seatbelt and a pelvic support/anti-slider belt (provides support to the pelvic/abdominal region to prevent hip thrusting or sliding). Interview with Employee 3 (nurse aide) on March 13, 2025, at 11:45 AM revealed that Resident 1 was unable to release or remove the above attachments on his body, but they were required to prevent a fall out of the wheelchair. Review of Resident 1's clinical record revealed admission to the facility on March 25, 1988, with diagnoses, which included anoxic brain damage (when the brain is deprived of oxygen for an extended (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 3 of 20 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 03/14/2025 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 0604 period, leading to brain damage), and osteoporosis (condition in which the bones become weak and brittle). Level of Harm - Minimal harm or potential for actual harm A review of an annual Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 9, 2025, revealed that Resident 1 BIMS interview (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information) was not completed, which indicated that the resident was unable to provide or did not provide answers to complete this section. The resident was dependent on staff for all self-care, transfers, and mobility. Residents Affected - Some Further review of the MDS, Section P- Restraints and Alarms, indicated that a trunk restraint was not used. A physician order dated September 30, 2024, revealed an order for OOB (out of bed) to specialized tilt-in-space wheelchair with chest harness and padded between the legs, slider belt at all times. Review of the Occupational Therapy (OT) Discharge summary dated [DATE], indicated that Resident 1 achieved the long-term goal of increased time out of bed/out of the room in the wheelchair with the use of a chest harness and slider belt for 6 hours in order to enhance comfort. Discharge recommendations included OOB in tilt-in-space wheelchair with chest harness and padded between the leg belt. Review of clinical record for Resident 1 revealed no evidence that the resident was evaluated for the need and use of physical restraints, including evaluation of the least restrictive measure needed to treat the resident's medical symptom. There was no physician documentation regarding the medical necessity for the chest harness, seatbelt, and slider belt. There was no documented evidence that the facility obtained informed consent prior to the use of restraints. There was no documented consent available in the clinical record. Interview with the Director of Rehabilitation (DOR) on March 13, 2025, at 12:50 PM revealed the facility had not identified the chest harness and slider belt as a physical restraint. The DOR reported that staff should not be using the standard seatbelt on the wheelchair. The DOR confirmed that the facility failed to conduct a restraint evaluation as indicated in the facility's Restraint Free Environment policy. The DOR was unable to provide documented evidence that the facility obtained informed consent from the resident's responsible party prior to the use of the physical restraints as indicated in the Use of Restraints policy. 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 211.10 (a) Resident care policies 28 Pa. Code 211.8 (c.1)(e)(f)Use of restraints 28 Pa. Code 211.12 (d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 4 of 20 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 03/14/2025 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility-initiated transfer notices and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for one resident out of the 21 residents sampled. (Resident 60). Findings include:: A review of Resident 60's clinical record revealed the resident was initially admitted to the facility on [DATE], with diagnoses that included atrial fibrillation (irregular heartbeat) and Chronic Obstructive Pulmonary Disease (COPD a progressive lung disease characterized by chronic respiratory symptoms and airflow limitations). A review of the clinical record revealed that Resident 60 was transferred to the hospital on June 28,2024 and was readmitted to the facility on [DATE]. A review of the clinical record failed to reveal documented evidence the facility provided the representative of the Office of the State Long Term Care Ombudsman with a written notice of the facility-initiated transfer and reason for the transfer on June 28,2024 An interview with the Nursing Home Administrator (NHA) on March 14,2025, at 11:45 a.m., confirmed the facility had no documented evidence indicating the representative of the Office of the State Long Term Care Ombudsman was informed of the transfer in writing. 28 Pa. Code 201.14(a) Responsibility of licensee. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 5 of 20 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 03/14/2025 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 0625 Level of Harm - Potential for minimal harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on a review of clinical records and staff interview it was determined the facility failed to provide residents or their representatives with written information of the facility's bed hold policy upon transfer to the hospital of one resident out of 21 residents sampled (Residents 39). Findings include: A review of Resident 39's clinical record revealed the resident was transferred to the hospital on January 16,2025 and returned to the facility on January 21,2025. There was no documented evidence the facility provided this resident and/or their representatives written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) at the time of transfer. Interview with the Nursing Home Administrator on March 13,2025 at 2:24 PM confirmed the facility was unable to provide documented evidence of the provision of a written notice of the facility's bed hold policy upon hospital transfer. 28 Pa Code 201.18 (b)(3) Management 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(2)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 6 of 20 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 03/14/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, and staff interview it was determined the facility failed to provide nursing services consistent with professional standards of quality by failing to follow a physician order to discontinue a treatment for one of 21 sampled residents (Resident 57). Residents Affected - Some 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. The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, 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. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records. According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments Clinical problems Communications with other health care professionals regarding the patient Communication with and education of the patient, family, and the patient's designated support person and other third parties. A review of the clinical record revealed Resident 57 was admitted to the facility on [DATE], with diagnoses which included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). A physician order dated January 14, 2025, noted an order for Bacitracin External Ointment (topical antibiotic which stops growth of bacteria) 500 units/gram to left side of scalp topically every day and evening for abrasion (superficial injury caused by rubbing or scraping away of the skin's outer layer often resulting in a minor wound with minimal bleeding). A nursing note dated January 20, 2025, indicated that the Certified Registered Nurse Practitioner (CRNP) evaluated the wound during wound rounds and issued a new order to discontinue the treatment, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 7 of 20 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 03/14/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm as the area had healed. The note also documented that the resident's representative was informed of the change. An observation of Resident 57 on March 13, 2025, at 8:00 AM, in the presence of Employee 1 (LPN), revealed no abrasions on the resident's scalp, including on the left side. Residents Affected - Some A review of Resident 57's Treatment Administration Records from January 20, 2025, through March 12, 2025, showed that facility staff continued to apply Bacitracin External Ointment twice daily, despite the wound being healed and the treatment discontinued. During an interview on March 13, 2025, at 8:30 AM, the Regional Nurse Consultant confirmed the abrasion on Resident 57's scalp had healed and acknowledged the treatment should have been discontinued on January 20, 2025. 28 Pa. Code 211.5 (f)(i)(ii)(iii)(ix) Medical Records 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 8 of 20 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 03/14/2025 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and staff interviews, it was determined that the facility failed to provide person-centered care by not ensuring compliance with physician orders for the management of a Peripherally Inserted Central Catheter (PICC) line, failed to maintain the availability of prescribed emergency supplies, and failed to meet the resident's clinical needs for one of 21 sampled residents (Resident 31). Residents Affected - Some Findings include: A review of clinical records revealed Resident was admitted to the facility on [DATE], with diagnoses to include lobar pneumonia (type of lung infections that affects an entire lobe of the lung), and systemic inflammatory response syndrome of non-infectious origin (widespread inflammatory response to a non-infectious trigger). A review of Resident 31's hospital records, including the PICC Insertion Documentation dated January 30, 2025, indicated the resident underwent placement of a single-lumen PICC line (a peripherally inserted central catheter, also called a PICC line, is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart, used for intravenous fluids, including antibiotics) in the right arm for intravenous administration of fluids, including antibiotics. Documentation noted the catheter's total length was 35 cm with an external length of 0 cm. A review of physician orders dated January 31, 2025, at 2:00PM, revealed the if the catheter is pulled out, staff must immediately apply pressure for 15-20 minutes to stop bleeding, verify catheter integrity, apply sterile gauze to the exit site if needed, and notify the physician. An additional physician order dated January 31, 2025, at 3:00 PM requiring an emergency PICC kit to be kept at bedside or on the resident's wheelchair and checked every shift. A review of Resident 31's Treatment Administration Record (TAR) for February and March 2025 showed that nursing staff documented the presence of the emergency PICC kit at bedside/on the wheelchair each shift. However, an observation conducted on March 12, 2025, at 2:50 PM, revealed no emergency PICC supplies were available in the resident's room or on the wheelchair. An interview with Employee 3 (Registered Nurse) on March 12, 2025, at 3:00 PM, confirmed that Resident 31 had a physician's order for emergency PICC line supplies but that no such supplies were present. Employee 3 stated that he had never observed an emergency kit at bedside or on the wheelchair since the resident's admission. Employee 3 was unable to explain why staff had been documenting the presence of the kit when it was not available. Further review of physician orders dated January 31, 2025, included a directive for nursing staff to measure the PICC line catheter length on admission and with each dressing change thereafter, every Thursday during the evening shift. A review of Resident 31's Nursing admission Evaluation (January 31, 2025), Medication Administration Record (February and March 2025), and nursing notes (January 31 - March 13, 2025) revealed no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 9 of 20 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 03/14/2025 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 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some documented evidence that nursing staff had measured and recorded the PICC line catheter length on admission or during weekly dressing changes as ordered. An interview with the Regional Clinical Nurse Consultant on March 13, 2025, at 12:55 PM, confirmed there was no documentation to support that the physician's orders for measuring and recording the PICC line length had been followed. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 10 of 20 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 03/14/2025 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 0698 Provide safe, appropriate dialysis care/services 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 review of clinical records and staff interview, it was determined the facility failed to provide person-centered care for one resident out of one resident receiving hemodialysis. (Resident 87). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 87 was admitted to the facility on [DATE], with diagnoses to include end-stage kidney disease with dependence on kidney dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). According to the clinical record, the resident had a left upper arm arteriovenous fistula (an AV fistula is a connection that's made between an artery and a vein for dialysis access. A surgical procedure, done in the operating room, is required to stitch together two vessels to create an AV fistula). Current physician orders dated January 30, 2025, indicated dialysis days and times (Monday, Wednesday, Friday at 11:30 AM), specific instructions for the left arm fistula, limb alert left upper extremity fistula, monitor for signs and symptoms of infection and/or bleeding, emergency fistula kit to the bedside, and emergency fistula kit to the wheelchair. However, the orders did not detail the specific care to be provided for the AV fistula in the event of an emergency. The orders also did not specify care to be provided for the AV fistula such as to check for bruit (abnormal swishing sound heard with a stethoscope over a blood vessel) and thrill (vibration felt over the chest wall by using one's hand) daily to ensure the fistula is functioning. Review of the resident's current care plan initially dated January 30, 2025, failed to include care specific to the resident receiving hemodialysis. The care plan did not include individualized interventions addressing the monitoring, care, maintenance, or emergency management of the AV fistula site, despite this being the resident's current dialysis access site. A physician order dated February 7, 2025, noted an order for 1000 cc fluid restriction for a diagnosis of end stage kidney disease. Further review of the care plan revised February 3, 2025, indicated the resident had increased nutrient needs related to illness/injury as evidenced by the need for hemodialysis treatments. Interventions to meet nutrient needs and weight stability included to honor food preferences, monitor for changes in meal completion, monitor weight as ordered, provide diet as ordered, and provide supplements as ordered. An intervention dated February 7, 2025, noted to follow 1000 cc fluid restriction as ordered. Further review of the clinical record revealed the resident was non-compliant with the fluid restriction. A physician order dated March 10, 2025, noted an order to discontinue the 1000 cc fluid restriction. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 11 of 20 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 03/14/2025 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The resident's care plan which was reviewed during the survey ending on March 14, 2025, was not updated to reflect that the resident's fluid restriction was discontinued on March 10, 2025. During an interview conducted on March 14, 2025, at 10:15 AM, the Director of Nursing (DON) confirmed the absence of physician orders and a care plan that included planned care and emergency measures specific to the AV fistula and hemodialysis for this resident. The DON confirmed the care plan was not revised to address the discontinuation of the fluid restriction based on the resident's non-compliance. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 12 of 20 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 03/14/2025 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 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. Based on observation, review of select facility policy, and staff interviews, it was determined that the facility failed to implement a process for providing pharmacy services, including access to emergency medications when not available onsite, and failed to maintain oversight of the facility's medication dispensing system. Findings include: A review of the facility Medication Ordering and Receipt Emergency Boxes and On-Site Stores Policy reviewed February 19, 2025, indicated the contract pharmacy supplies an On-site Stores (Pyxis like system, an automated, medication system, located in the facility) to be utilized by the facility in the case of new admissions, urgent new orders, received after-hours, or when immediate medication administration is required. Procedures to include, On-site Stores medication is secured in compliance with Federal, State, and Local regulations for drug storage and inaccessible to unauthorized persons. If the On-site Stores is not exchanged regularly, a pharmacy representative will perform an on-site audit inspection and remove expired drugs on a consistent basis. A review of the facility's Medication Ordering and Receipt, After-Hours Pharmacy Service policy revealed that emergency pharmaceutical services are available 24 hours a day, 365 days a year. According to the policy, emergency medication needs should be met using onsite supplies provided by the pharmacy, including an emergency box, interim box, starter kit, controlled substance interim box, and an electronic cabinet, as permitted by regulations. The policy further states that STAT (immediate) medication requests can be made to the pharmacy and that a corporate pharmacist is available 24/7 to either dispense medications from the pharmacy or arrange for dispensing from a backup pharmacy to meet the facility's medication needs. A review of the facility's emergency medication supply and observation of the On-site Stores Cubex Medflex (automated medication dispensing system) located in the second floor nursing unit medication room on March 13, 2025, at 11:00 AM in the presence of employee 2 (registered nurse) revealed that a courier from the contacted pharmacy delivers medications in bulk to the facility and that she is then responsible for filling the automated dispensing system. At the time of the survey ending March 14, 2025, the facility failed to provide documentation of pharmacy oversight, including routine monthly audits for expired medications and medication availability. During an interview on March 14, 2025, at 11:00 AM the regional nurse consultant confirmed the facility did not have a backup emergency pharmacy, despite the policy stating that one should be available. The regional nurse consultant stated the facility relied solely on an out of state-based pharmacy with daily courier deliveries. Additionally, she acknowledged that facility nursing staff, rather than trained pharmacy personnel, were responsible for restocking the automated medication dispensing system. The regional nurse consultant further confirmed that facility staff had received training from a pharmacist on proper restocking procedures, but no documentation of pharmacy oversight or staff training on proper restocking of the On-Site Stores Cubex Medflex was provided during the survey. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 13 of 20 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 03/14/2025 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 0755 The facility lacked a process to ensure emergency medication availability and failed to maintain proper oversight of the medication dispensing system. Level of Harm - Minimal harm or potential for actual harm Refer F836 Residents Affected - Few 28 Pa. Code 211.9 (a)(l)(d)(k) Pharmacy Services. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 14 of 20 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 03/14/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 review of select facility policy, observation, and staff interview it was determined the facility failed to ensure that drugs were stored at an acceptable temperature on two of two nursing units. Findings include: Review of the facility Medication Storage policy last reviewed February 19, 2025, indicated that medications and biologicals (medications that come from living organisms) are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a secured refrigerator with a thermometer to allow temperature monitoring. An observation of the medication refrigerator located in the nurse's station on the Third Floor Nursing Unit on March 11, 2025, at 7:20 PM in the presence of employee 3 (registered nurse) revealed that various medications which required refrigerator were being stored in the refrigerator. The thermometer in the refrigerator read 50 degrees Fahrenheit. A second observation of the medication refrigerator located in the nurse's station on the Third Floor Nursing Unit on March 11, 2025, at 8:10 PM revealed the refrigerator temperature remained at 50 degrees Fahrenheit. The medications had been removed from the refrigerator. Interview with employee 3 (registered nurse) at this time confirmed the director of nursing (DON) was informed of the concern with the refrigerator and the medications were temporarily moved to the refrigerator on the Second Floor Nursing Unit. Interview with the nursing home administrator (NHA) on March 11, 2025, at approximately 8:30 PM confirmed the refrigerator on the Third Floor Nursing Unit was not maintaining an acceptable temperature and was being replaced. An observation of the medication room on the Second Floor Nursing Unit on March 13, 2025, at 11:00 AM in the presence of Employee 2. It was noted the medication refrigerator contained multiple unopened Ozempic pens (medication used to help lower blood sugar). However, there was no thermometer inside the refrigerator and no temperature monitoring log was available for review to verify the medications were being stored at the appropriate temperature. Employee 2 stated that a thermometer should be present in the medication refrigerator and that a temperature monitoring log should be maintained to ensure licensed staff are monitoring the internal refrigerator temperature. An interview with the regional nurse consultant on March 13, 2025, at approximately 12:00 PM confirmed that all medication refrigerators were to have a thermometer present inside each refrigerator and licensed staff were to monitor medication refrigerator temperatures at least daily and record the date and temperature on a temperature monitoring log. The regional nurse consultant also indicated that medications which required refrigeration were to be stored at an acceptable temperature. 28 Pa Code 211.12(d)(1) Nursing services. 28 Pa Code 211.9(a)(1)(k) Pharmacy services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 15 of 20 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 03/14/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on staff interview and a review of employee qualifications it was determined that the facility failed to employ a full-time qualified director of food and nutrition services manager in the absence of a full-time qualified dietitian. Findings include: The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship. During initial tour of the food and nutrition services department on March 11, 2025, at 6:20 PM the food and nutrition services director (FSD) stated that he had been the FSD since January 21, 2025. The FSD stated that he had a culinary background but did not yet have a certification to meet the requirements for a qualified foodservice director based on current federal regulation. The FSD stated that he does visit residents for food preferences. The FSD further stated the full-time registered dietitian (RD) had recently quit, and the current RD works remotely and was available via e-mail and telephone. Interview with the nursing home administrator (NHA) on March 12, 2025, at approximately 9:00 AM confirmed that the full-time RD's last day of employment was on March 7, 2025. The NHA confirmed the current RD worked remotely on a part-time basis. The NHA confirmed the facility failed to provide documented evidence the facility employed a full-time qualified food service director in the absence of a full-time qualified dietitian. The NHA failed to provide documented evidence the services of the remote RD included face to face interactions with residents to ensure appropriate nutritional oversight for residents in the facility. The NHA failed to provide documented evidence the current remote RD was scheduled to provide frequently scheduled consultations to the FSD. 28 Pa Code 201.18 (e)(1)(6) Management. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 16 of 20 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 03/14/2025 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on a review of the facility's automated emergency medication system, applicable state regulations, facility policies, and staff interviews, it was determined that the facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring pharmacy services necessary for daily pharmacy operations according to state requirements of Pa. Code title 49. Findings include: A review of Pennsylvania Code title 49, part I, subpart A, chapter 27 - STATE BOARD OF PHARMACY, 49 Pa. Code § 27.204 - Automated medication systems revealed the following: (a) This section establishes standards applicable to licensed pharmacies that utilize automated medication systems which may be used to store, package, dispense or distribute prescriptions. (b) A pharmacy may use an automated medication system to fill prescriptions or medication orders provided that: (1) The pharmacist manager, or the pharmacist under contract with a long-term care facility responsible for the dispensing of medications if an automated medication system is utilized at a location which does not have a pharmacy onsite, is responsible for the supervision of the operation of the system. (4) The automated medication system must electronically record the activity of each pharmacist, technician or other authorized personnel with the time, date and initials or other identifier so that a clear, readily retrievable audit trail is established. A pharmacist will be held responsible for transactions performed by that pharmacist or under the supervision of that pharmacist. (c) The pharmacist manager or the pharmacist under contract with a long-term care facility responsible for the delivery of medications shall be responsible for the following: (1) Reviewing and approving all policies and procedures for system operation,safety, security, accuracy, access and patient confidentiality. (2) Ensuring that medications in the automated medication system are inspected, at least monthly, for expiration date, misbranding and physical integrity, and ensuring that the automated medication system is inspected, at least monthly, for security and accountability. (3)Assigning, discontinuing or changing personnel access to the automatedmedication system. (4) Ensuring that the automated medication system is stocked accurately, and an accountability record is maintained in accordance with the written policies and procedures of operation. (5) Ensuring compliance with the applicable provisions of State and Federal law. (6) Set forth methods that ensure that access to the automated medication system for stocking and removal of medications is limited to licensed pharmacists or the pharmacist's designee acting under (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 17 of 20 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 03/14/2025 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the supervision of a licensed pharmacist. An accountability record which documents all transactions relative to stocking and removing medications from the automated medication system must be maintained. (g) The pharmacist manager shall be responsible for ensuring that, prior to performing any services in connection with an automated medication system, all licensed practitioners and supportive personnel are trained in the pharmacy's standard operating procedures with regard to automated medication systems set forth in the written policies and procedures. The training shall be documented and available for inspection. A review of the facility policy Medication Ordering and Receipt Policy reviewed February 19, 2025, revealed that a designated staff member will be responsible for immediately adding the medications to the Automated Medication System and updating the quantities in the system. An interview with Employee 2 (registered nurse) on March 13, 2025 at 10:10 A.M. revealed she was the designated staff member responsible for receiving the medications from the pharmacy courier and filling the Automated Medication System. Based on the provided information during the survey ending March 14, 2025, the facility failed to specifically ensure the oversight and management of the automated medication system as required by Pennsylvania Code Title 49, Chapter 27, which mandates pharmacist supervision, system inspections, and proper medication accountability. The maintenance of a readily retrievable audit trail and documented oversight of the automated medication system. The Pennsylvania code Title 49 require that automated medication systems be managed under the supervision of a pharmacist and include documentation of oversight activities, system inspections, and accountability for stocking and removing medications. However, the facility failed to provide documentation verifying the required oversight and management of the automated medication system were conducted. During an interview on March 14, 2025, at 11:00 AM, the Regional Nurse Consultant failed to provide documented evidence the contracted pharmacy was adhering to the Pennsylvania code regarding pharmacy services. The Regional Nurse Consultant failed to provide documented evidence regarding oversight and management of the system by contracted pharmacy staff. Refer F755 28 Pa. Code 201.18 (b)(3)(e)(1) Management. 28 Pa. Code 211.9 (a)(l)(d)(k)(l)(1)(2)(3) Pharmacy Services. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 18 of 20 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 03/14/2025 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 0880 Provide and implement an infection prevention and control program. 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, select facility policy, observations, and staff interviews, it was determined the facility failed to implement enhanced barrier infection control procedures for one out of 21 residents sampled (Resident 38), properly store clean towels designated for resident use in one out of two shower rooms on the Third Floor Nursing Unit, and maintain infection control practices related to reduce the potential for infections for one (Resident 36) out of two sampled residents with an indwelling urinary Foley catheter (flexible tube which is placed in the bladder to drain urine). Residents Affected - Some Findings include: A review of facility policy titled Enhanced Barrier Precautions, last reviewed by the facility on February 19, 2025, revealed it is the facility policy to expand the use of personal protective equipment and refer to the use of gowns and gloves during high-contact resident care activities that provided opportunities for transfer of multi-drug-resistant organisms (MDROs) to staff hands and clothing. The policy indicates nursing home residents with wounds and indwelling medical devices are especially high risk for both the acquisition of and colonization with MDROs. The policy indicates any resident who requires enhanced barrier precautions will have clear signage posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. A clinical record review revealed Resident 38 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (a condition that affects a person's ability to move and maintain balance and posture, caused by damage to the brain) and dysphagia (difficulty swallowing). A physician's order, initially dated January 14, 2025, indicated that Resident 38 required enhanced barrier precautions (interventions implemented to prevent the transmission of novel or targeted multidrug-resistant organisms) due to the presence of a gastrostomy tube (surgically placed tube that provides direct access to the stomach for feeding, hydration, or medication delivery). Observations conducted on March 12, 2025, at 12:20 PM, and March 13, 2025, at 9:10 AM, revealed that no signage was posted outside Resident 38's room to indicate enhanced barrier precautions, nor were there any instructions regarding PPE requirements. . Interviews with Employee 4 Licensed Practical Nurse (LPN) and Employee 5 (Nurse Aide) on March 13, 2025, at 9:10 AM confirmed that no enhanced barrier precautions had been implemented for Resident 38, contrary to facility policy and infection control standards. Observations conducted on March 11, 2025, at 7:30 PM, in the Third Floor Nursing Unit single shower room revealed that clean towels were placed inside the sink. A subsequent observation on March 11, 2025, at 10:30 AM, in the presence of the Director of Nursing (DON), confirmed that a pile of clean towels was stored inside the sink. An interview with the DON at this time confirmed that towels should not be stored in the sink, as this poses a risk of contamination. The DON acknowledged the facility is responsible for ensuring (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 19 of 20 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 03/14/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some infection control procedures are fully implemented, including the proper storage of resident linens such as towels. A review of clinical records revealed Resident 36 was admitted to the facility on [DATE], with diagnoses to include neuromuscular dysfunction of the bladder (occurs when the nerves that control bladder function are damaged, leading to difficulty emptying or controlling the bladder), and benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty). Review of nursing documentation dated January 9, 2025, at 3:44 PM revealed Resident 36 was admitted to the facility with a Foley catheter (a flexible tube inserted through the urinary opening and into the bladder. The device drains the urine into a drainage bag). An observation on March 11, 2025, at 8:25 PM, revealed that Resident 36 was resting in bed, and the urine collection bag from the resident's Foley catheter was lying on its side, directly on the floor. A subsequent observation on March 13, 2025, at 8:25 AM, again revealed that the urine collection bag was in direct contact with the floor, creating an increased risk for contamination and infection. An interview with the Infection Preventionist on March 14, 2025, at 11:00 AM, confirmed the facility failed to maintain Resident 36's Foley catheter in a manner that would prevent the potential for urinary tract infections (UTIs). The Infection Preventionist further acknowledged the facility failed to uphold appropriate infection control techniques for a resident with an indwelling Foley catheter. 28 Pa. Code 211.10 (a)(d) Resident care policies. 28 Pa. Code 211.12 (c )(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395456 If continuation sheet Page 20 of 20