Health inspection·January 18, 2024

F 0684 · Level of Harm - Minimal harm or potential for actual harm Communications with other health care professionals regarding the patient · Residents Affected - Few Communication with and education of the patient, family, and the patient ' s designated support person and other third parties. Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses to include kidney stones, acute kidney failure, and diabetes. The resident was noted to be cognitively intact. Nursing documentation dated December 20, 2023, at 11:57 AM revealed that the new orders were received from the resident's physician for Ondansetron HCL 4 mg (brand name Zofran) every six hours, as needed, for nausea/vomiting. Review of the resident's clinical record revealed no evidence that the resident was experiencing nausea/vomiting at that time. Review of Resident 1's Medication Administration Record (MAR) dated December 2023 revealed that Ondansetron HCL 4 mg was administered at 12:05 PM on December 21, 2023, for complaints of nausea which was effective. There was no documentation of any further nursing assessment or evaluation completed at that time. A physician progress note dated December 20, 2023, revealed that the resident was examined in the resident's room. According to the progress note, the resident's daughter felt that the resident needed to be tested for COVID, influenza, a full respiratory panel. The physician documented that during the assessment, Resident 1 had mild congestion, denied headache, sore throat, shortness of breath, chest pain, or changes in bowel and bladder. The physician stated that the resident's congestion would be treated symptomatically and that there was no reason to test the resident's for COVID, Flu or complete a full respiratory panel noting that if symptoms worsen, we can discuss further. She has had no cough needing medication. There was no mention of Resident 1 experiencing nausea or vomiting during the physician's assessment in the physician progress note. Nursing documentation dated December 27, 2023, at 1:28 PM indicated that Resident 1 had complaints of a cough and a physician ordered received for geri-tussin (cough medicine) 5 mL every six hours as needed for cough for 5 days. There was no documented nursing assessment at that time to reflect the presence of any other symptoms or nursing evaluation for changes in condition. According to the December 2023 MAR, nursing did not administer the cough medicine to the resident until until 8:25 PM on December 27, 2023, at which time it was effective. There was no documented evidence that nursing staff had consulted with the physician regarding the resident's new respiratory/cold symptom to ascertain if testing was desired to rule out COVID, flu (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395691 If continuation sheet Page 2 of 6 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 395691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverstreet Manor 440 North River Street Wilkes-Barre, PA 18702 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 or RSV as requested by the resident's family during discussion with the physician on December 20, 2023. Level of Harm - Minimal harm or potential for actual harm The resident's MAR revealed that on December 29, 2023, at 12:30 AM nursing administered Ondansetron for complaints of nausea, and Tylenol for complaints of a headache. Residents Affected - Few There was no documented nursing assessment to reflect the presence of any other symptoms or a nursing evaluation of the resident's changes in condition in response to the resident's continued complaints of nausea, and the additional complaint of a headache. At 3:18 AM on December 29, 2023, Resident 1 experienced an unwitnessed fall. According to the clinical record, staff found the resident on the floor in the resident's room by the bathroom door. The resident complained of back pain. The resident stated that she became unsteady on her feet getting up to use bathroom with walker. The resident also stated that she was nauseous and had vomited once on the previous shift. At time of fall assessment, the resident's temperature was 99.1, Farenheit, heart rate was 99, respiratory rate was 17, and blood pressure was 128/77. When reviewed during the survey ending January 18, 2024, the last documented evidence of the resident's vital signs was completed on November 12, 2023. There was no documented evidence that between November 12, 2023, and December 29, 2023, that nursing staff had obtained the resident's vital signs as part of an evaluation of the resident while she was experiencing symptoms and displaying changes in condition. At 6:45 AM on December 29, 2023, the resident was medicated again with Ondansetron for complaints of nausea, and Tylenol for complaints of pain which were effective. Nursing documentation dated December 29, 2023, at 12:02 PM indicated that new orders were received from the physician for bloodwork and a urinalysis with culture and sensitivity to be completed on January 2, 2024. Review of physician progress note date December 28, 2023, revealed that the resident was seen and examined in her room, resting in bed. According to the note, the resident was still having upper respiratory symptoms but denied chills and sweats and she had no related GI (gastrointestinal) symptoms. There was no evidence that her increased use of the medication, Zofran, for nausea and vomiting was evaluated when assessing the presence of the GI symptoms. On December 29, 2023, at 2:32 PM, additional orders were obtained from alternate physician for blood work to be completed on December 30, 2023, instead of waiting until January 2, 2024. On December 29, 2023, at 7:41 PM, Resident 1 was observed ambulating in the hall, stumbling while grey in color, hanging onto the rail in a vomit-soaked gown. According to the nursing documentation, the resident was confused and disoriented, her temperature was elevated at 101.2, Farenheit, heart rate was 64, respiratory rate was 20, blood pressure was 138/50, and her oxygen saturation level was 84%. A physician order was received to send the resident to the emergency room for evaluation and treatment. Interview with the Director of Nursing (DON) on January 18, 2024, at 3:00 PM, confirmed the facility's licensed and professional nursing staff failed to record complete and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395691 If continuation sheet Page 3 of 6 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 395691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverstreet Manor 440 North River Street Wilkes-Barre, PA 18702 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 accurate assessment of the resident's change in condition in the resident's clinical record and demonstrate timely and consistent consultation with physician services regarding the resident's changes in condition and ongoing symptoms. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services Residents Affected - Few 28 Pa. Code 211.5 (f) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395691 If continuation sheet Page 4 of 6 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 395691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverstreet Manor 440 North River Street Wilkes-Barre, PA 18702 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in two of two resident pantries. (Station 1 and Station 2) Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observation of Station 2 resident pantry refrigerator on January 18, 2024, at approximately 10:30 AM revealed the top of the refrigerator was soiled with debris, brown stains, and coated with a a sticky substance. Observation inside the freezer revealed a plastic grocery bag, which contained frozen hamburger patties, a Blue Bunny ice cream cup, and a large plastic fountain drink cup with a straw that was ¾ full of a pink frozen liquid. The items were not labeled to identify to whom they belonged or dated when they were placed in the freezer. Observation of the refrigerator revealed a resealable clear bag that contained cut celery, another re-sealable clear bag with cheese slices and sleeve of crackers, two large Styrofoam cups on the door filled with a tan liquid that resembled chocolate milk, an opened half gallon of 2% milk, a grocery bag, which contained a whole chocolate cream pie. None of the items were labeled and/or dated. In the bottom left-hand drawer, there was an insulated personal lunch bag, and the bottom of the drawer was heavily soiled with food debris and a pink sticky substance. Further observation of the Station 2 resident pantry revealed that in the cabinet above the microwave there were 2 brown plastic bowls filled with raisin bran, and 2 brown plastic bowls filled with cheerios. Each bowl was covered with plastic wrap but not dated to indicate when they were dispensed. In the cabinet below the microwave there was an opened 2-liter plastic bottle of lemon lime soda ½ full that was not labeled and/or dated to indicate when it was opened. Observation of the Station 1 resident pantry on January 18, 2024, at approximately 10:50 AM, revealed that the clear plastic ice scoop was placed in the scoop holder on the wall to the left of the ice machine. Further observation of the holder revealed that the bottom of the ice scoop was resting in water, and on the inside of the holder there was a small area of a black mold-like substance observed just below the water line. Observation of the refrigerator revealed a clear plastic container with a red lid which contained a yellow liquid substance that resembled soup. The item was labeled with room [ROOM NUMBER] and was dated December 29, 2023. A ceramic container with flowers and clear lid was not labeled or dated, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395691 If continuation sheet Page 5 of 6 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 395691 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverstreet Manor 440 North River Street Wilkes-Barre, PA 18702 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sandwich labeled with room [ROOM NUMBER]W dated December 31, 2023, a white plate with two large slices of dried pepperoni pizza labeled room [ROOM NUMBER]D was not dated to indicate when it was placed in the refrigerator, and a personal lunch bag containing a bottle of water, sandwich, and plastic container of food was on the refrigerator door. In the cabinet above the microwave there were 2 brown bowls filled with cheerios, and 1 bowl of raisin bran. Each bowl was covered with plastic wrap and were not labeled and/or dated. The doors to the cabinet below the microwave were not properly functioning. The door on the left's bottom hinge was broken, and the door on the right was heavily soiled with a sticky substance which caused resistance when attempting to open the door. The cabinet below the sink was heavily soiled with dirt and debris and had evidence of heavy water damage. Interview with the Nursing Home Administrator and Director of Nursing on January 18, 2024, at 2:30 PM confirmed that sanitary practices for food storage should be maintained in the resident pantry refrigerator. 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395691 If continuation sheet Page 6 of 6