Health inspection·October 21, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure that a resident was free from neglect by not providing care with the required assistance of two staff members as planned to ensure safety and prevent major injuries. As a result, one resident (Resident 1) sustained multiple subdural hematomas and closed nasal fracture requiring hospital evaluation, representing actual harm for one resident out of one sampled for abuse prohibition.Findings include: A review of the facility's policy entitled Abuse and Neglect Clinical Protocol, last reviewed by the facility on May 2, 2025, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. It is the policy of the facility, as part of the strategy to prevent abuse, neglect, mistreatment, and exploitation of residents, that volunteers, employees, and contractors hired by the facility are expected to be able to identify neglect as it may occur against residents and prevent resident neglect as a priority throughout all levels of the organization. A review of the facility's policy entitled Managing Falls and Fall Risks, last reviewed by the facility on May 2, 2025, revealed it is the policy of the facility that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis (severe weakness or paralysis on one side of the body) due to cerebral infarction (brain tissue damage caused by interruption of blood flow). A Minimum Data Set Assessment (MDS, a federally mandated standardized assessment process conducted at specific intervals to plan resident care) of Resident 1, dated September 18, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (Brief Interview for Mental Status, a tool to assess the residents' attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment) and indicated the resident was dependent (relying on someone for physical support) for rolling side to side in bed. Review of Resident 1's care plan for risk of falls, initiated December 28, 2021, indicated the resident was at risk for falls due to impaired balance, poor coordination, and a history of falls. Interventions included the use of a bariatric bed (type of bed used to accommodate overweight or larger individuals) and mattress and encouragement to change positions slowly. Continued review of Resident 1's current comprehensive person-centered care plan indicated the resident had an ADL (activities of daily living) self-care performance deficit related to physical limitations. Planned resident-centered interventions revealed the resident required two-staff assistance with bed mobility initiated on May 6, 2024, with revision on September 29, 2025. A clinical record review for Resident 1 revealed a form titled Lift, Transfer, and Reposition, dated September 12, 2025, that revealed Resident 1 required two staff members for repositioning in bed. A nurse's progress note written by Employee 1 (Registered Nurse Supervisor) dated October 10, 2025, at 2:25 AM, documented that on October 9, 2025, at 10:20 PM, Employee 1 received notification from the nurse assigned to Resident 1 that Resident 1 had been found lying on the floor on their back after a fall from bed. Upon assessment, Resident 1 was noted to have a superficial laceration (wound) on the bridge of the nose measuring 1.2 centimeters (cm) in length and two additional superficial cuts on the forehead measuring 0.5 cm and 0.8 cm, accompanied by mild swelling. Resident 1 complained of right shoulder pain. The bleeding was controlled, the physician was notified of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395691 If continuation sheet Page 2 of 7 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 10/21/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few incident, and orders were received to transfer Resident 1 to the emergency department for further evaluation. Resident 1 was subsequently transported to the hospital for medical assessment and treatment. A nurse's progress note written by Employee 1 (RN Supervisor) dated October 10, 2025, at 2:53 AM revealed that an in-service was conducted with the assigned aide for Resident 1 regarding proper two-person assist for dependent residents, and emphasizing stabilization during turning and hygiene care A review of outside hospital records provided by the facility, dated October 10, 2025, revealed that Resident 1 presented to the emergency department after a fall at the facility that occurred while an aide was rolling Resident 1 during routine care. The documentation indicated that Resident 1 fell onto his right shoulder and forehead, resulting in an abrasion (a scrape or rubbing away of the skin) and a hematoma (a localized collection of clotted blood outside the blood vessels) extending from the nasal bridge into the forehead. A CT scan (computed tomography imaging test that uses X-rays and a computer to create detailed cross-sectional images of the body) of the head revealed multiple subdural hematomas (collections of blood between the brain and its protective covering), with the largest on the left side, as well as intraparenchymal hemorrhage (bleeding within the brain tissue), bleeding between the scalp and skull, swelling of the right frontal scalp, and mild bilateral paranasal (pertaining to the air-filled cavities within the skull bones around the nasal cavity) soft tissue swelling. Imaging also raised suspicion of a non-displaced fracture (a bone break without separation of the bone fragments) of the left nasal bone. Hospital documentation noted that Resident 1 was receiving hospice services at the facility, and the resident's family elected for discharge from the emergency department with return to the facility following evaluation. A nurse's progress note written by Employee 2, Licensed Practical Nurse (LPN), dated October 10, 2025, at 9:16 AM revealed that Resident 1 returned from the emergency room post-fall with a diagnosis of subdural hematoma and closed fracture of the nasal bone. The facility's investigative documentation initiated October 10, 2025, by Employee 1 (RN Supervisor) revealed that Employee 3 (Nurse Aide, NA) had rolled Resident 1 onto his side in bed by herself to provide incontinence care. Resident 1 slowly fell out of bed to the floor. Further review revealed that Employee 4, LPN, was called to the room by Employee 3, NA, and Resident 1 was on the floor between beds laying on his right arm and shoulder, and bleeding was noted from his face. The investigation determined that Employee 3 was aware that two-person assistance was required but provided care alone. The facility substantiated neglect based on failure to follow the resident's plan of care. A written statement from Employee 4 (LPN), dated October 9, 2025 (no time indicated), confirmed they responded to the call and found Resident 1 was on the floor between the beds, lying on his right arm and shoulder, and bleeding was noted from his face, and Employee 3 was next to the resident. A written witness statement completed by Employee 3, Nurse Aide, dated October 10, 2025 (no time indicated), revealed that while completing rounds after dinner, Employee 3 entered Resident 1's room to change the resident's brief. Employee 3 rolled Resident 1 onto the resident's side in bed without assistance, despite being aware that Resident 1 required the assistance of two staff members for bed mobility. The statement indicated that Resident 1 occasionally flinched during care. While reaching to retrieve a clean brief, Employee 3 maintained one hand on Resident 1, who then began to roll toward the window side of the bed. Employee 3 climbed onto the bed in an attempt to control the movement and assisted Resident 1 to the floor; however, Resident 1's face struck the oxygen concentrator positioned beside the bed. Employee 3 then placed a bath blanket under Resident 1's head and immediately called for help. A telephone interview conducted with Employee 3, Nurse Aide, on October 21, 2025, at 1:30 PM revealed that on October 9, 2025, at 10:20 PM, Employee 3 provided personal care for Resident 1. During care, Employee 3 rolled Resident 1 onto the resident's side (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395691 If continuation sheet Page 3 of 7 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 10/21/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete to clean the resident. After reaching for a clean brief, Resident 1 continued rolling toward the window on the left side of the bed. Employee 3 reported being unable to prevent the movement but was able to grasp Resident 1 and control the descent to the floor. Before reaching the floor, Resident 1's head struck an oxygen concentrator situated next to the bed. Following the incident, Resident 1 was observed on the floor between both beds with facial bleeding. Assistance was obtained, and Resident 1 was lifted back into bed with the use of a mechanical lift. Employee 3 confirmed awareness that Resident 1 required the assistance of two staff members for bed mobility during care. A review of human resources documentation revealed Employee 3 was hired on August 27, 2025, and completed initial in-service training on that date, including abuse prevention education. Employee 3 was suspended on October 9, 2025, pending investigation and was terminated on October 14, 2205. There was no documented evidence that Employee 3 followed the resident's care plan, which required two staff members for safe bed mobility. Employee 3 rolled Resident 1 in bed by herself at 10:20 PM on October 9, 2025, and turned her back to grab a brief, resulting in Resident 1 rolling out of bed onto the floor and sustaining a forehead laceration and subdural hematoma. An interview with the Director of Nursing on October 21, 2025, at 3:00 PM revealed that facility documentation reflected the internal investigation substantiated neglect related to the failure to provide care with two-person assistance as required by the plan of care. The substantiated neglect resulted in actual physical harm to Resident 1, including multiple subdural hematomas, a facial laceration, and a closed nasal fracture. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 201.29 (a) Resident Rights 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12 (d)(5) Nursing Services. Event ID: Facility ID: 395691 If continuation sheet Page 4 of 7 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 10/21/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined the facility failed to maintain food delivery equipment in a clean and sanitary condition to prevent potential food contamination for four of four food delivery carts observed (Pine, Oak, Willow, and Spruce hallways).Findings include: Safe food handling and sanitation standards established by the United States Department of Agriculture (USDA) and Food and Drug Administration (FDA) require all equipment and utensils used in the storage, preparation, and delivery of food to be kept clean and in good repair. Equipment must undergo a two-step process consisting of cleaning (removal of visible soil and debris) and sanitizing (application of heat or chemical solution to reduce microorganisms that may cause illness). Harmful bacteria that cause foodborne illness cannot be seen, smelled, or tasted; therefore, strict adherence to cleaning and sanitizing procedures is required to prevent contamination. On October 21, 2025, the following observations were made during meal service: At 11:45 AM, the stainless-steel food delivery cart on the Pine hallway had a large amount of dried food and liquid residue on the top, sides, and doors. The interior floor of the cart contained accumulated food particles, paper debris, and visible dirt. At 11:55 AM, the stainless-steel food delivery cart on the Oak hallway had dried food residue, liquid stains, and visible dirt on the exterior and interior surfaces. At 12:10 PM, the stainless-steel food delivery cart on the [NAME] hallway had dried food and liquid residue on the top, sides, and doors, with paper debris and dirt on the floor of the cart. At 12:30 PM, the stainless-steel food delivery cart on the Spruce hallway had dried food and liquid residue on the top and doors, with accumulated food debris and dirt on the floor of the cart. The metal shelving unit on the left side of the cart was broken, and the detached metal brackets were resting inside the cart. During an interview on October 21, 2025, at 3:15 PM, the Nursing Home Administrator, the above observations were reviewed. 28 Pa code 201.18(b)(1) Management Event ID: Facility ID: 395691 If continuation sheet Page 5 of 7 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 10/21/2025 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 0926 Have policies on smoking. 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, facility policy, and resident and staff interviews, it was determined the facility failed to implement its established smoking policy to ensure resident safety. The facility failed to post the smoking policy in a conspicuous and legible manner, failed to ensure that required smoking safety equipment was available in the designated smoking area, and failed to ensure smoking materials were properly secured for nine residents who smoke (Residents 2, 3, 4, 5, 6, 7, 8, 9, and 10).Findings include: A review of the facility's policy titled Facility Smoking Policy, last reviewed May 2, 2025, revealed that smoking be permitted only in designated areas that are separate from resident care areas, well ventilated, and equipped with portable fire extinguishers. The policy identified the designated smoking location as the courtyard accessible through the door near the laundry and outside the Station 1 dayroom, prohibited oxygen use in smoking areas, and required that residents be evaluated for smoking safety upon admission and re-evaluated quarterly and with a change in condition. The policy required that residents be supervised until evaluated as safe to smoke independently, that smoking times be scheduled at 10:30 AM, 1:30 PM, 4:00 PM, and 7:00 PM, and that each resident's smoking status be reflected in the care plan. In addition, the policy required smoking supplies, including cigarettes, matches, and lighters, to be labeled with the resident's name and room number, maintained by staff, and stored at the reception desk. Residents were not permitted to keep their own lighters, lighter fluid, or matches. During the entrance conference on October 21, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility permits smoking in designated areas. A list of smoking residents provided by the facility included Residents 2, 3, 4, 5, 6, 7, 8, and 9. Resident 10 was observed smoking during the survey but was not included on the list provided to the survey team. An observation conducted on October 21, 2025, at approximately 10:15 AM, revealed Residents 3 and 4 smoking on the patio outside the laundry room without staff supervision. Each resident possessed their own cigarettes and lighter and independently lit their cigarettes. Resident 2 was observed entering a door code into the keypad outside the smoking entrance door. Resident 2 was interviewed at that time and stated that she knew the door code and went to the smoking area independently in her wheelchair whenever she wished. She stated she did not wear a smoking apron and kept her cigarettes and lighter at her bedside. Further observation of resident areas and lobby spaces on October 21, 2025, revealed that the facility's smoking policy was not posted in any resident area or common space. At approximately 10:20 AM the same day, Residents 3 and 4 were interviewed and stated that they knew the door code to the smoking area and went out to smoke without notifying staff. They reported they kept their smoking materials and smoked independently. An observation on October 21, 2025, at 10:53 AM revealed Resident 10 in her wheelchair in the first-floor A hallway with a pack of cigarettes and a lighter in her lap. She wheeled herself to the smoking area door, entered the key code, went outside to the patio, lit her cigarette, and began smoking without staff supervision. Resident 2 was admitted [DATE], with a diagnosis of emphysema (a chronic, progressive lung disease that causes shortness of breath). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated April 18, 2024, directed staff to check her room for smoking materials, secure smoking materials at the front-lobby reception desk, and educate family and visitors not to leave smoking items in her room. Resident 3 was admitted to the facility on [DATE], with diagnosis to include Chronic Obstructive Pulmonary Disease (COPD). A quarterly MDS (Minimum Data Set, a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 8, 2025, revealed a BIMS score of 15 (Brief Interview for Mental Status) is a mandatory tool used to screen and Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395691 If continuation sheet Page 6 of 7 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 10/21/2025 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete identify the cognitive condition of residents a score of 13 to 15 indicates intact cognition). A smoking assessment dated [DATE], identified him as an independent smoker. His care plan, dated August 19, 2025, directed staff to educate family and visitors not to leave smoking materials in his room and to store such materials at the front-lobby desk. Resident 4 was admitted [DATE], with a diagnosis of COPD. A quarterly MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified him as an independent smoker. A care plan initiated May 21, 2025, and revised June 24, 2025, instructed staff to check his room for smoking materials, secure them at the reception desk, educate family and visitors about smoking policies, and ensure oxygen was removed before smoking and replaced after. Resident 5 was admitted [DATE], with COPD. A quarterly MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated May 3, 2024, included, remove oxygen to smoke, reapply when done smoking, check resident room for smoking materials (cigarettes, matches, lighters, etc.) at the lobby reception desk. Educate family and visitors not to leave smoking materials in resident room, educate resident to interventions and facility smoking policy and procedures and to secure smoking materials (cigarettes, matches and lighters at the front lobby desk. Resident 6 was admitted on [DATE], with emphysema. An annual MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. Her care plan, initiated September 13, 2023, instructed staff to check her room for smoking materials, secure them at the reception desk, and educate residents and visitors regarding smoking procedures. Resident 7 was admitted [DATE], with a diagnosis of hypertension (elevated blood pressure). An annual MDS dated [DATE], revealed a BIMS score of 14 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated May 12, 2024, instructed staff to check her room for smoking materials, secure them at the reception desk, and educate the resident and family on smoking policy expectations. Resident 8 was admitted [DATE], with COPD. A quarterly MDS dated [DATE], revealed a BIMS score of 14 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated May 12, 2024, directed staff to remove oxygen before smoking, reapply it after, check for smoking materials in her room, and secure them at the reception desk. Resident 9 was admitted [DATE], with COPD. A quarterly MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated May 14, 2025, directed staff to remove oxygen before smoking, reapply after, check her room for smoking materials, and secure them at the reception desk. Resident 10 was admitted [DATE], with chronic respiratory failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide). A quarterly MDS dated [DATE], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE], identified her as an independent smoker. A care plan initiated July 9, 2025, directed staff to check her room for smoking materials, secure them at the reception desk, educate family and visitors not to leave smoking materials in the room, and ensure adherence to the smoking policy. An interview conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on October 21, 2025, at 2:00 PM, revealed that residents maintained smoking materials such as cigarettes and lighters in their rooms and that the smoking policy was posted only outside the smoking-area exit door. The DON and NHA indicated that the facility's current practices for securing smoking materials and posting the policy were not consistent with the facility's written smoking policy. 28 Pa. Code 201.18 (b)(1)(3) Management 28 Pa. Code 209.3 (a) Smoking. 28 Pa Code 211.10 (c) (d)Resident care policies Event ID: Facility ID: 395691 If continuation sheet Page 7 of 7