# EDGAR Filing Document

**Accession Number:** 0001594748
**File Stem:** 0000731012-23-000006
**Filing Date:** 2023-1
**Character Count:** 10874
**Document Hash:** 9d5c23308bfefe094e4c304156f1d8e8
**Contains OCR:** False
**Source Format:** 

## Filing Content

## Filing Summary
**0000731012-23-000006.hdr.sgml**: 20230105

**ACCESSION NUMBER**: 0000731012-23-000006

**CONFORMED SUBMISSION TYPE**: 4

**PUBLIC DOCUMENT COUNT**: 2

**CONFORMED PERIOD OF REPORT**: 20230103

**FILED AS OF DATE**: 20230105

**DATE AS OF CHANGE**: 20230105

**REPORTING-OWNER**: 

**OWNER DATA:**
- **COMPANY CONFORMED NAME:** Bundick Jason J
- **CENTRAL INDEX KEY:** 0001594748

**FILING VALUES:**
- **FORM TYPE:** 4
- **SEC ACT:** 1934 Act
- **SEC FILE NUMBER:** 000-12015
- **FILM NUMBER:** 23513486

**MAIL ADDRESS:**
- **STREET 1:** 3220 TILLMAN DRIVE
- **STREET 2:** SUITE 300
- **CITY:** BENSALEM
- **STATE:** PA
- **ZIP:** 19020
**ISSUER**: 

**COMPANY DATA:**
- **COMPANY CONFORMED NAME:** HEALTHCARE SERVICES GROUP INC
- **CENTRAL INDEX KEY:** 0000731012
- **STANDARD INDUSTRIAL CLASSIFICATION:** SERVICES-NURSING & PERSONAL CARE FACILITIES [8050]
- **IRS NUMBER:** 232018365
- **STATE OF INCORPORATION:** PA
- **FISCAL YEAR END:** 1231

**BUSINESS ADDRESS:**
- **STREET 1:** 3220 TILLMAN DRIVE
- **STREET 2:** SUITE 300
- **CITY:** BENSALEM
- **STATE:** PA
- **ZIP:** 19020
- **BUSINESS PHONE:** 2159381661

**MAIL ADDRESS:**
- **STREET 1:** 3220 TILLMAN DRIVE
- **STREET 2:** SUITE 300
- **CITY:** BENSALEM
- **STATE:** PA
- **ZIP:** 19020

## Ex-24

```
<pre>
POWER OF ATTORNEY

Know all by these presents that the undersigned hereby constitutes and appoints each of John Shea, and Michael Harrity signing singly, as the undersigned's true and lawful attorneys-in-fact to:

1)execute for and on behalf of the undersigned Forms 3, 4 and 5 in accordance with Section 16 of the Securities Exchange Act of 1934, as amended (the "Exchange Act") relating to Healthcare Services Group, Inc. (the "Company");

2)do and perform any and all acts for and on behalf of the undersigned which may be necessary or desirable to complete and execute any such Forms 3, 4 or 5, complete and execute any amendment or amendments thereto, and timely file such form with the United States Securities and Exchange Commission and any stock exchange or similar authority; and

3)take any other action of any type whatsoever in connection with the foregoing which, in the opinion of such attorney-in-fact, may be of benefit to, in the best interest of, or legally required by, the undersigned, it being understood that the documents executed by such attorney-in-fact on behalf of the undersigned pursuant to this Power of Attorney shall be in such form and shall contain such terms and conditions as such attorney-in-fact may approve in such attorney-in-fact's discretion.

The undersigned hereby grants to each such attorney-in-fact full power and authority to do and perform any and every act and thing whatsoever requisite, necessary, or proper to be done in the exercise of any of the rights and powers herein granted, as fully to all intents and purposes as the undersigned might or could do if personally present, with full power of substitution or revocation, hereby ratifying and confirming all that each such attorney-in-fact, or each such attorney-in-fact's substitute or substitutes, shall lawfully do or cause to be done by virtue of this power of attorney and the rights and powers herein granted.  The undersigned acknowledges that the foregoing attorneys-in-fact, in serving in such capacity at the request of the undersigned, are not assuming any of the undersigned's responsibilities to comply with Section 16 of the Exchange Act.  The undersigned acknowledges that such attorney-in-fact is not assuming: (i) any liability for the undersigned's responsibility to comply with the requirements of the Act; (ii) any liability of the undersigned for any failure to comply with such requirements; or (iii) any obligation or liability of the undersigned for profit disgorgement under Section 16(b) of the Act.

This Power of Attorney shall remain in full force and effect until the undersigned is no longer required to file Forms 3, 4 and 5 with respect to the undersigned's holdings of and transactions in securities issued by the Company, unless earlier revoked by the undersigned in a signed writing delivered to the foregoing attorneys-in-fact.

IN WITNESS WHEREOF, the undersigned has caused this Power of Attorney to be executed as of this 27th day of January, 2016.

Signature /s/ Jason J. Bundick

Print Name Jason J. Bundick
</pre>
```

### UNITED STATES SECURITIES AND EXCHANGE COMMISSION
**Washington, D.C. 20549**

## FORM 4

### STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP

[ ] Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue. See Instruction 1(b).

[ ] Check this box to indicate that a transaction was made pursuant to a contract, instruction or written plan for the purchase or sale of equity securities of the issuer that is intended to satisfy the affirmative defense conditions of Rule 10b5-1(c). See Instruction 10.

---

| | | |
|:---|:---|:---|
| **1. Name and Address of Reporting Person**<sup>*</sup><br>Bundick Jason J<br><sub>(Last) (First) (Middle)</sub><br>3220 TILLMAN DRIVE<br>SUITE 300<br><sub>(Street)</sub><br>BENSALEM, PA 19020<br><sub>(City) (State) (Zip)</sub> | **3. Date of Earliest Transaction (Month/Day/Year)**<br>2023-01-03 | **5. Relationship of Reporting Person(s) to Issuer**<br>(Check all applicable)<br>[ ] Director [ ] 10% Owner<br>[X] Officer (give title below) [ ] Other (specify below)<br>_EVP/Gen. Counsel/Corp. Secty._ |
| **2. Issuer Name and Ticker or Trading Symbol**<br>HEALTHCARE SERVICES GROUP INC [ HCSG ] | **4. If Amendment, Date of Original Filed (Month/Day/Year)**<br>  | **6. Individual or Joint/Group Filing (Check Applicable Line)**<br>[X] Form filed by One Reporting Person<br>[ ] Form filed by More than One Reporting Person |

---

## Table I - Non-Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | 3. Transaction Code (V) | 3. Transaction Code (V) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 4. Securities Acquired (A) or Disposed of (D) | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| 1. Title of Security | 2. Transaction Date | 2A. Deemed Execution Date | Code | V | Amount | (A) or (D) | Price | 5. Amount of Securities Beneficially Owned | 6. Ownership Form | 7. Nature of Indirect Beneficial Ownership |
| Common Stock | 2023-01-04 |  | M |  | 1200 | A | $0 | 19440 | D |  |
| Common Stock | 2023-01-04 |  | M |  | 1700 | A | $0 | 21140 | D |  |
| Common Stock | 2023-01-03 |  | M |  | 2817 | A | $0 | 23957 | D |  |
| Common Stock | 2023-01-04 |  | M |  | 1498 | A | $0 | 25455 | D |  |
| Common Stock | 2023-01-04 |  | M |  | 2364 | A | $0 | 27819 | D |  |
| Common Stock | 2023-01-04 |  | F |  | 3661 | D | $0 | 24158 | D |  |

---

## Table II - Derivative Securities

---

|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | 4. Transaction Code (V) | 4. Transaction Code (V) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 5. Number of Derivative Securities Acquired (A) or Disposed of (D) | 6. Date Exercisable and Expiration Date | 6. Date Exercisable and Expiration Date | 7. Title and Amount of Underlying Securities | 7. Title and Amount of Underlying Securities | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
| 1. Title of Derivative Security | 2. Conversion or Exercise Price | 3. Transaction Date | 3A. Deemed Execution Date | Code | V | (A) | (D) | Date Exercisable | Expiration Date | Title | Amount or Number of Shares | 8. Price of Derivative Security | 9. Number of Derivative Securities Beneficially Owned | 10. Ownership Form | 11. Nature of Indirect Beneficial Ownership |
| Phantom Stock | <sup>(1)</sup> | 2023-01-03 |  | A |  | 947 |  | <sup>(2)</sup> | <sup>(2)</sup> | Common Stock | 947.0 | $12 | 3111<sup>(3)</sup> | D |  |
| Restricted Stock Units | <sup>(1)</sup> | 2023-01-04 |  | M |  |  | 1200 | <sup>(4)</sup> | <sup>(4)</sup> | Common Stock | 1200.0 | $0 | 0 | D |  |
| Restricted Stock Units | <sup>(1)</sup> | 2023-01-04 |  | M |  |  | 1700 | <sup>(5)</sup> | <sup>(5)</sup> | Common Stock | 1700.0 | $0 | 1700 | D |  |
| Restricted Stock Units | <sup>(1)</sup> | 2023-01-03 |  | M |  |  | 2817 | <sup>(6)</sup> | <sup>(6)</sup> | Common Stock | 2817.0 | $0 | 5634 | D |  |
| Restricted Stock Units | <sup>(1)</sup> | 2023-01-04 |  | M |  |  | 1498 | <sup>(7)</sup> | <sup>(7)</sup> | Common Stock | 1498.0 | $0 | 4494 | D |  |
| Restricted Stock Units | <sup>(1)</sup> | 2023-01-04 |  | M |  |  | 2364 | <sup>(8)</sup> | <sup>(8)</sup> | Common Stock | 2364.0 | $0 | 9454 | D |  |

---

### Footnotes:

(1) Shares issued at the conversion rate of 1-for-1.

(2) Shares of Phantom Stock are payable in-kind following termination of the Reporting Person's employment with Issuer.

(3) Acquired pursuant to an Issuer contribution under the Healthcare Services Group, Inc. Deferred Compensation Plan.

(4) These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2018 grant date.

(5) These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2019 grant date.

(6) These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 3, 2020 grant date.

(7) These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2021 grant date.

(8) These Restricted Stock Units shall vest at the rate of 20% annually, commencing on the first anniversary of the January 4, 2022 grant date.

**Signature:** /s/ Michael Harrity, by Power of Attorney  
**Date:** 2023-01-05

### Remarks:

Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly.

* If the form is filed by more than one reporting person, see Instruction 4 (b)(v).

** Intentional misstatements or omissions of facts constitute Federal Criminal Violations See 18 U.S.C. 1001 and 15 U.S.C. 78ff(a).

Note: File three copies of this Form, one of which must be manually signed. If space is insufficient, see Instruction 6 for procedure.

**Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number.**