Riverstreet Manor

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation and staff interview, it was determined that the facility failed to maintain a clean and sanitary environment for 2 of 2 resident shower areas in the facility and maintain a clean and safe outdoor smoking area Findings include: On October 21, 2025, at 1:00 P.M., observations of the Area 145 shower/bathroom revealed multiple items stored inappropriately within resident bathing areas, including two shower chair buckets, a mechanical lift sling, a pair of sneakers, and an open plastic bag of briefs placed inside the bathtub. The bathtub's waterspout was coated with a thick layer of dried white residue. In the first shower stall, the perimeter of the floor was coated with a black, sticky substance. The floor surface showed visible soil and buildup. A stainless-steel soap dispenser on the wall exhibited visible streaks and brown discoloration, and the ceiling vent was layered with lint. The air conditioning/heating ceiling unit also had visible accumulations of dust and debris. The shower bed in the second shower stall was observed with a white powdery film and areas of dried residue. In the Area 158 shower room, the perimeter of the flooring contained a similar black, sticky buildup. A large rust stain was visible on the wall beneath the handrails.

Two ceiling cuts were noted, and the ceiling vent displayed significant lint accumulation. A shower chair within this area was stained with brown discoloration. The wheelchair scale had visible buildup and liquid residue, and the stand-up mechanical lift showed dried deposits and surface staining. The bathtub in the same area contained a pair of wheelchair leg rests. The floors throughout the shower room exhibited visible debris, including plastic and paper materials, and the edges contained black adhesive-like residue. An

observation of the outdoor smoking area near the laundry entrance revealed extensive cigarette litter across the concrete surface, including ashes and cigarette butts. Three white plastic patio chairs were coated with black residue consistent with cigarette ash. The patio table contained ashes and cigarette debris. Four surrounding fabric chairs appeared worn and soiled, with several burn holes noted on the seat fabric. During an interview on October 21, 2025, at 3:00 P.M., the Nursing Home Administrator acknowledged that all facility areas are expected to be always maintained in a clean and sanitary condition.28 Pa. Code 201.18 (e)(1) (2.1) Management

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

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:

If continuation sheet

Printed: 04/13/2026 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

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:

If continuation sheet

Printed: 04/13/2026 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

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 REDACTED], 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 REDACTED], with a diagnosis of COPD. A quarterly MDS dated [DATE REDACTED], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE REDACTED], 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 REDACTED], with COPD. A quarterly MDS dated [DATE REDACTED], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE REDACTED], 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 REDACTED], with emphysema. An annual MDS dated [DATE REDACTED], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE REDACTED], 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 REDACTED], with a diagnosis of hypertension (elevated blood pressure). An annual MDS dated [DATE REDACTED], revealed a BIMS score of 14 (cognitively intact). A smoking assessment dated [DATE REDACTED], 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 REDACTED], with COPD. A quarterly MDS dated [DATE REDACTED], revealed a BIMS score of 14 (cognitively intact). A smoking assessment dated [DATE REDACTED], 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 REDACTED], with COPD. A quarterly MDS dated [DATE REDACTED], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE REDACTED], 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 REDACTED], with chronic respiratory failure (a long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide). A quarterly MDS dated [DATE REDACTED], revealed a BIMS score of 15 (cognitively intact). A smoking assessment dated [DATE REDACTED], 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:

If continuation sheet