Health inspection·September 1, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observations and staff interviews, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean, orderly, and homelike environment in resident areas on one of three resident units (B-Wing). Findings included: An observation on August 29, 2023, at 10:42 a.m. of the bathroom in resident room B8 revealed horizontal black scuff marks on the inside of the bathroom door, chipped areas of paint on the bottom corner of the door frame, a crack in the drywall in the restroom to the left of the door extending approximately 4 feet horizontally, a cracked plastic white sink drain cover, and floor molding peeling off the wall to the left of the toilet, exposing the inside of the wall. An observation on August 29, 2023, at 10:43 a.m., of resident room B8 revealed paint chipping from the bottom section of the metal frame, black and gray scuff marks on the lower portion of the wall adjacent to the exit, and unfinished plaster work covering an area approximately 3 feet x 0.5 feet on the same wall. An observation on August 29, 2023, at 10:45 a.m., of the B-Wing resident lounge revealed a spare closet door measuring approximately 2 feet x 7 feet unsecured and leaning on a supply cabinet. An area of torn wall paper measuring approximately 4 inches x 3 inches, a phone jack separated from the wall exposing the inside of the wall, 3 window sills with black dust, dirt, and debris extending the length of the sills, a transparent light covering in the drop ceiling with visible debris, chipped paint on the lower portion of the door frame, and cracked floor tiles extending the length of the lounge doorway entrance were observed in the resident lounge. An observation on August 29, 2023, at 10:56 a.m. of resident room B9 revealed brown stains on the floor in front of the heating unit, dark brown and tan stains on the wall to the right of the heating and cooling unit, dust buildup on the lower intake vents and top of the heating and cooling unit, a brown substance on the heating and cooling control panel, and gray stains on the window curtains. An observation on August 29, 2023, at 11:10 a.m. of the bathroom in resident B5 revealed horizontal black and gray scuff marks as well as peeling and chipped paint on the inside of both bathroom doors. The observation also revealed chipped and peeling paint on the lower section of each door frame, a 2-foot scratch in unfinished plaster to the right of the sink, and a white toilet support device with chipped paint exposing a dark metal. An observation on August 29, 2023, at 11:45 a.m., of resident room B14 revealed the floor molding Page 1 of 15 395249 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few strip to the right of the bathroom door peeling from the wall, tan and gray stains on the middle and lower sections of the wall, and white plaster on the middle section of the wall. Also, observation of the bathroom in resident room B14 revealed unfinished rough white plaster work to the right and left of the sink, a floor molding strip with a gap exposing the inside of the wall behind the toilet and under the sink, a discolored ceiling block with a brown stain, and additional brown stains on the wall directly below the ceiling block to the left and above the sink. An observation on August 31, 2023, at 11:30 a.m., of the B-Wing Shower Room revealed a large green area of stripped paint and black scuff marks on the inside of the shower room door, a white shower chair with four rusted wheel coverings and a missing wall tile to the right of the shower room door. During an interview on September 1, 2023, at approximately 8:30 a.m., the Nursing Home Administrator and Director of Nursing confirmed that the residents' environment should be kept in good repair and maintained in a clean and homelike manner. 28 Pa Code 201.18(e)(2.1) Management 28 Pa Code 201.29(a) Resident Rights 395249 Page 2 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0641 Ensure each resident receives an accurate assessment. 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 and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 22 sampled (Resident 5). Residents Affected - Few Findings include: The RAI (Resident Assessment Instrument) manual indicates that they are to base the weight on the most recent measure in the last 30 days. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment or previous weight is not available, weigh the resident again. A review of Resident 5's clinical record revealed the resident was admitted to the facility on [DATE]. A review of Resident 5's quarterly MDS assessment dated [DATE], Section K0200, Height and Weigh Section B Weight revealed a dash indicating that no weight taken. The resident's documented weights were noted as January 1, 2023 178.4 pounds and February 8, 2023, the resident's weight was noted as 177.1 pounds. The date The date of the MDS was February 7, 2023, and the resident's last weight was obtained on January 1, 2023, and more than 30 day prior to the assessment date. There was no indication the facility weighed the resident timely to accurately complete the February 7, 2023, MDS assessment. Interview with the Director of Nursing on August 31, 2023 at 1:20 p.m. she could not explain why the resident was not weighed as part of the February 7, 2023, MDS assessment. 395249 Page 3 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

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 a review of clinical records and staff interview it was determined that the facility failed to follow physician orders for bowel protocol for one resident out of 22 sampled (Residents 90) to promote normal bowel activity to the extent practicable and failed to follow physician orders for medication administration for one resident out of 22 sampled (Resident 42). Residents Affected - Some Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). A review of the clinical record revealed that Resident 90 was admitted to the facility on [DATE], with diagnoses to include, hereditary ataxia (degenerative changes in the brain and spinal cord that lead to uncoordinated gait, poor eye-hand coordination and abnormal speech) and migraines. The resident had physician orders dated May 6, 2023, for the following bowel regimen: - Milk of Magnesia Suspension 400 MG/5ML (Magnesium Hydroxide), give 30 ml by mouth as needed for constipation if no BM (bowel movement) for 3 days on 7-3 (7AM to 3 PM shift); -Fleet Enema, 7-19 GM/118 ML (Sodium Phosphates), insert 1 dose, rectally as needed for constipation Administer day 4 on 7-3 shift if no BM. Review of Resident 90's report of bowel activity from the Documentation Survey Report v2 for August 2023, revealed that the resident did not have a bowel movement on August 1, 2023, August 2, 2023, August 3, 2023, August 4, 2023, August 5, 2023, and August 6, 2023. Review of Resident 90's August 2023 Medication Administration Record (MAR) revealed no documented evidence that staff implemented and administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. During an interview with the Director of Nursing (DON) on August 31, 2023, at 11:00 AM, the DON was unable to provide evidence that physician ordered bowel protocol was followed for the resident during the period without bowel activity. A review of the clinical record revealed that Resident 42 was admitted to the facility on [DATE], with diagnoses that included dementia and anxiety. Further review of Resident 42's clinical record indicated that the resident had physician orders dated August 10, 2023, for Quetiapine Fumarate (Seroquel) 12.5 milligrams (mg) by mouth one time a day (9:00 a.m.) every other day for 3 days then discontinue. Review of Resident 42's MAR for August 2023 indicated that the medication was administered August 10, 12, 14, 16, 18, 20 22, and 24, 2023, although the physician discontinued the antipsychotic drug 395249 Page 4 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0684 on August 14, 2023, nursing staff continued administer the drug until August 24, 2023. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing on August 31, 2023 at 11:30 a.m. confirmed the psychoactive medication was administered until August 24, 2023 despite the physician order to discontinue the drug on August 14, 2023. Residents Affected - Some 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Clinical records 395249 Page 5 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain mobility and functional abilities of two of four residents sampled (Resident 89 and 20). Findings included: A review of the clinical record of Resident 89 revealed admission to the facility on May 5, 2023, with diagnoses to include pain in leg and edema. A review of Resident 89's Physical Therapy Discharge summary dated [DATE], indicated that the resident was to receive Restorative Nursing Program (RNP) for ambulation. The discharge summary indicated that the ambulation program was established and staff trained for the resident to ambulate up to 150 feet with rolling walker with assist of one person. There was no documented evidence at the time of the survey ending September 1, 2023, that the resident was receiving the RNP program for ambulation following discharge from skilled physical therapy on June 2, 2023. A review of the clinical record of Resident 20 revealed admission to the facility on July 28, 2022, with diagnoses to include seizures, delusional disorders and insomnia. A review of Resident 20's Physical Therapy Discharge summary dated [DATE], indicated that the resident was to receive RNP for ambulation. The discharge summary indicated the ambulation program was established and staff trained for the resident to ambulate up to 150 feet with rolling walker with assist of one person. There was no documented evidence at the time of the survey ending September 1, 2023, that the resident was receiving the RNP program for ambulation following discharge from skilled physical therapy on July 19, 2023. Interview with the Director of Nursing on August 31, 2023, at 11:11 AM failed to provide evidence that the residents were provided and/or receiving RNP programs as recommended by Physical Therapy upon discharge from skilled services. 28 Pa. Code: 211.5(f) Clinical records 28 Pa. Code: 211.12(c)(d)(3)(5) Nursing services 395249 Page 6 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility incident reports and staff interview, it was determined that the facility failed to implement effective interventions, including staff supervision, to promote resident safety and prevent repeated falls for one resident of 22 sampled residents (Resident 20). Findings include: A review of the clinical record revealed that Resident 20 was admitted to the facility on [DATE], with diagnoses to include seizures, delusional disorders and insomnia. An admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 4, 2022, indicated that the resident exhibited a severe cognitive impairment with a BIMS score of 5 (Brief Interview for Mental Status - a tool to assess cognitive function; a score of 0-7 indicates severe cognitive impairment) and required extensive staff assistance for transfers and ambulation. Review of the facility Fall Risk Evaluation dated August 26, 2022, revealed that the resident was at high risk for falls related to impaired balance, change in gait pattern (walking), and poor cognition. Review of the resident's care plan, initially dated July 29, 2022, indicated that the resident was at a risk of falls related to gait and balance problems, psychoactive drug use, delusional disorder and seizures. Planned interventions to keep the resident free of injury were to encourage resident to use walker when ambulating, long handled reacher to assist picking up objects not in reach, nonskid slipper socks/rubber sole shoes, reminder signs to use walker and nonskid socks, TV power button labeled, and offer chair by room as resident likes to hang out. The resident's care plan also noted that Resident 20 was an elopement risk/wanderer due to exit seeking behaviors, date-initiated September 22, 2022. Planned interventions to maintain resident's safety were to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book and place resident photograph at reception/exit (Center Watch Book). Review of an incident report dated December 30, 2022, at 1:28 PM revealed that staff witnessed the resident running toward the door in the dining room when he tripped on a rug and fell to his knees. The resident reported he was running to go out the door in the dining room and tripped. The report noted that the resident was wearing proper footwear and the Wanderguard was in place. The resident was assessed, and no injuries were noted. Predisposing factors included the rugs, behavior, gait imbalance, impaired memory and ambulating without assist. The new intervention was the resident was educated to not run in the hallways. Review of an incident report dated January 10, 2023, at 6:33 PM revealed that the resident was observed sitting with his back against the bed with his legs extended out in front of him. His slippers were on, but had worn out grips on bottom of soles. Resident stated that he was trying to get out of bed to go to the bathroom and his feet slid out in front of him. Resident assessed, no injuries reported . Neuro checks initiated. The new intervention was the resident was educated not to wear 395249 Page 7 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0689 slippers anymore due to worn out soles. Sneakers should be worn only. Level of Harm - Minimal harm or potential for actual harm Review of an incident report dated January 18, 2023, at 8:55 PM revealed that the resident was found siting on floor near roommate's bed, legs extended. Resident had on appropriate footwear according to the report. The resident was ambulating without walker. Resident reported he tripped when he was coming out of the bathroom and hit the left side of his head on the roommate's footboard. The resident was assessed, and no injuries were reported. Neuro checks initiated. Predisposing factors included gait imbalance and ambulating without assist. The new intervention was to encourage resident to use walker when ambulating. Residents Affected - Some Review of an incident report dated February 25, 2023, at 5:53 PM revealed that staff observed the resident sitting on the floor, on his buttocks, outside of the bathroom. Resident had his sneakers on, but the right heel was out of the shoe. The walker was by the resident's bed against the wall. The resident reported that while coming from the bathroom and heading toward his bed, he tripped over his feet and fell on his buttocks. Resident assessed, no injuries reported. Neuro checks initiated. Predisposing factors included gait imbalance, ambulating without assist. The new intervention included resident educated on calling for assistance, review of his non-compliance with transfers and ambulation, and referral to Physical Therapy. Review of an incident report dated March 29, 2023, at 4:08 AM revealed that the resident was found lying on the floor on his back in front of his bed. The resident reported he was trying to look in his dresser. The resident was assessed, no injuries were reported. Predisposing situational factors include ambulating without assist and improper footwear. The new interventions were Physical Therapy screen and a sign hung in resident's room to remind him to wear nonskid socks. Review of an incident report dated May 24, 2023, at 1:24 PM revealed that the resident was heard yelling help and found sitting on the floor on his buttocks between the beds. The resident reported he tripped and fell. Was not using walker. Resident assessed; no apparent injuries noted. Small, reddened mark under eye, resident unable to state where he hit his face. Neuro checks initiated. Intervention was Physical Therapy screen. Review of an incident report dated June 12, 2023, at 8:30PM revealed resident observed on floor in room by window. The resident reported he was walking over to the window. Resident assessed with reported head laceration and right pinky finger injury. Sent to ER for evaluation. Predisposing factors included gait imbalance and ambulating without assist. Intervention included Physical Therapy screen. Review of an incident report dated July 1, 2023, at 12:07 AM revealed resident observed lying on his right side on the bathroom floor under the sink. Resident unable to provide statement of events. Resident assessed with 2.54 cm x 2.54 cm contusion on right eyebrow. Vomit found on clothing and floor. During assessment resident appeared to experience seizure lasting 10 seconds. Resident sent to ER and was admitted to the hospital with seizures, compression fracture, and aspiration pneumonia. readmission to facility on July 3, 2023, with no new interventions documented. The resident was severely cognitively impaired with poor safety awareness, but the facility failed to demonstrate the provision of necessary staff supervision, at the level and frequency required to prevent repeated falls. The facility planned approaches, which required the resident's cognitive awareness, to include use of the assistance device for ambulation and appropriate footwear, but failed to ensure the resident was adequately supervised based on the resident's severe cognitive 395249 Page 8 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0689 impairments, unsafe behaviors, and history of falls. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Rehab (DOR) on September 1, 2023, at 9:00 AM confirmed that the resident requires staff assistance for all transfers and ambulation. Residents Affected - Some Interview with the Nursing Home Administrator (NHA) on September 1, 2023, at 9:30 AM, failed to provide evidence that the facility provided sufficient supervision and effective safety measures to the resident to prevent repeated falls. 28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services 395249 Page 9 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0692 Provide enough food/fluids to maintain a resident's health. 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 and select facility policies and staff interview, it was determined that the facility failed to timely and consistently monitor resident weights and address significant weight changes to assure maintenance of acceptable nutritional parameters for one of 22 sampled residents (Resident 24) and timely to confirm a significant weight loss one of 22 sampled residents (Resident 14). Residents Affected - Some Findings include: The facility policy Weight Policy dated as reviewed July 12, 2023, indicated that each resident will be weighed monthly by the 10th day of the month. New and re-admission residents' weight will be obtained within 24 hours of admission, and weekly x 4 weeks unless indicated otherwise. The resident's height will be obtained within 24 hours of admission as well. Height and Weight data are to be documented in the resident's EMR. The assigned CNA under the supervision of the licensed nurse will obtain the resident weights. Weights will be obtained utilizing the same scale week-to-week and month-to-month, when possible, to ensure consistency. The type of scale utilized will be noted on the resident Weight Record. Any resident with weight changes of five or more pounds will be re-weighed within 72 hours post the original weight by the assigned CNA/designee and nurse. The Dietician will review the medical record of residents with significant weight changes (>/=5% in 1 month, >/=7.5% in 3 months, >/= 10% in 6 months). Interventions will be recommended, as needed. The nurse will confirm with the MD and order recommendations made by the Dietitian. Interventions that are initiated in response to a weight change will be reflected in the care plan. Residents with significant weight loss/gain will be further reviewed by the IDCP Team meetings. Review of Resident 24's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (lung disease that blocks airflow, making it difficult to breathe), muscle weakness, and mild protein calorie malnutrition. Review of Resident 24's Significant Change in Status Minimum Data Set [(MDS) is a federally mandated standardized assessment process completed periodically to plan resident care), dated July 21, 2023, revealed that the resident was cognitively intact with a Brief Interview for Mental Status [(BIMS) section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 15 indicates intact cognition] score of 15. The resident's height was 47 inches, weighed 139 pounds (lbs.), had an unplanned significant weight loss of 5% or more in the past month, and was prescribed a therapeutic diet. A Dietary Progress Note created by the Registered Dietitian (RD) dated July 5, 2023, at 10:56 AM, revealed a Weight Warning that the resident had a -5.8% or 8.6 lbs. weight loss. A re-weight was requested. The facility failed to obtain a re-weight to verify the resident's significant weight loss and notify the physician and representative of the resident's significant weight loss according to facility policy. Resident 24 was admitted to the hospital on [DATE], and returned to the facility on July 16, 2023. Review of Resident 24's admission Nutritional Assessment, dated July 17, 2023, revealed the RD recommended weekly weights for 4 weeks. 395249 Page 10 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A weekly weight was not obtained until August 1, 2023, at 1:59 PM, 15 days after the recommended intervention for weekly weights for close monitoring. No additional weights were obtained by the end of the survey ending September 1, 2023. Interview with Employee 1 (Registered Dietitian) on August 31, 2023, at 10:20 AM, confirmed that the re-weight from the July 5, 2023, progress note was not obtained to verify the significant weight loss. Employee 1 also confirmed that weekly weights were not obtained for Resident 24 upon his re-admission to the facility as per RD's recommendation and the facility weight policy. Interview with the Nursing Home Administrator (NHA) on September 1, 2023, at approximately 9:20 AM, confirmed that the facility failed to obtain residents weights as per the facility's weight policy, and failed to notify the physician and RP of significant weight changes. Clinical record review revealed that Resident 14 was admitted to the facility on [DATE] and had diagnoses which included dementia and protein-calorie malnutrition. Review of Resident 14's resident's weight record revealed: May 1, 2023 265.0 pounds June 9, 2023 250.8 pounds and a 14.2 pound 5.35% significant weight loss June 14, 2023 209.0 pounds and a 41.8 pound 16.66% significant weight loss June 19, 2023 205.0 pounds Facility policy indicates that any resident with weight changes of five or more pounds will be re-weighed within 72 hours post the original weight by the assigned CNA/designee and nurse. The facility did not re-weight the resident within 72 hours post the original weight of June 9, 2023, and the weight on June 14, 2023, to confirm the significant weight losses. Interview with Employee 1 (Registered Dietitian) on August 31, 2023, at 10:20 AM, confirmed that the re-weights from June 9, 2023 and June 14, 2023 was not obtained to verify the significant weight loss. 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services. 28 Pa Code 211.10 (a)(c)(d) Resident care policies. 395249 Page 11 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 22 residents (Resident 84). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 84 was admitted to the facility on [DATE], and had diagnoses, which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Further review of Resident 84's clinical record revealed that the resident had frequent behaviors of rejecting and resisting the provision of care. The resident's behaviors noted in progress notes, described the resident as yelling, screaming, and attempting to bite and hit staff when providing daily care. A review of the resident's current care plan initially dated May 19, 2022, in effect at the time of the survey ending September 1, 2023, revealed no documented evidence that the facility had developed an individualized person-centered plan for the resident's dementia care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety and using individualized, non-pharmacological approaches to care, including purposeful and meaningful activities that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. An interview with the director of nursing on August 31, 2023, at approximately 2:00 PM confirmed the facility failed to develop and implement an individualized person-centered plan to address the resident's dementia. 28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services 395249 Page 12 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 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. 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). Initial tour of the food and nutrition services department in the presence of the foodservice director on August 29, 2023, at 9:00 AM revealed two opened 46 containers of nectar-thickened juice and a 32 ounce of nectar-thickened dairy beverage on the shelf in the walk-in cooler, which were not dated when opened. Review of the manufacturer labels on the beverage containers revealed nectar-thickened juice is to be used within 10 days after opening and dairy beverage is to be used within four days of opening. Interview with the foodservice director at this time confirmed that the food and nutrition services department is to maintain acceptable practices for food storage and open dates were to be placed on each beverage container once opened. 395249 Page 13 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 that the facility failed to offer and/or provide the influenza immunization to one of eight residents reviewed (Resident 42). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 42 was admitted to the facility on [DATE]. Nurses notes on October 31, 2022 at 12:57 p.m. indicated that a call was placed to the resident's responsible party to offer the resident the influenza vaccine, a message was left and awaiting a return call. An influenza consent form dated November 18, 2022, noted that no return call and that no consent was obtained. However, there was no evidence of any follow-up with the resident's responsible party from October 31, 2022, to November 18, 2022 to inquire about the influenza vaccine. Nurse's notes dated November 16, 2022, at 1:42 p.m. indicated that Resident 42 was not eligible for the pneumococcal vaccine and the physician and the resident's responsible party were aware, but failed to address asking the resident's responsible party about the influenza immunization. Interview with the Director of Nursing on August 31, 2023 at 12:45 p.m. confirmed the lack of follow up with the resident's responsible party from October 31, 2022 to November 18, 2022 to inquire about the influenza vaccine. 28 Pa Code 211.12 (c)(d)(1)(5) Nursing services 28 Pa Code 201.29 (a) Resident rights 395249 Page 14 of 15 395249 09/01/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on staff interviews and a review of facility training and orientation records, the facility failed to provide training to agency staff on the facility's procedures related to activities that constitute abuse, neglect, exploitation, or the misappropriation of resident property and resident abuse prevention for two of the nine employees interviewed (Employees 2 and 3). Findings included: During an observation conducted on the second floor on August 29, 2023, at 12:55 p.m., Employee 2 was observed working in the facility's B-Wing nursing station. An interview at this time revealed that Employee 2, LPN, was employed by a nurse staffing agency and working at the facility for the first time on the day of this interview. Employee 2 stated that the facility did not provide this nurse training on the facility's abuse prohibition policy and procedures to identify and report abuse, neglect, exploitation, or misappropriation of resident property or resident abuse prevention. During an observation conducted on the second floor on August 30, 2023, at 10:42 a.m., Employee 3, LPN, was observed working on the facility's B-Wing. An interview at this time revealed that Employee 3 was employed by a nurse staffing agency and was working at the facility for the first time on the day of this interview. Employee 3 stated that the facility did not provide the employee training on the facility's abuse prohibition policy and procedures related to abuse, neglect, exploitation, or misappropriation of resident property or resident abuse prevention. During an interview on August 30, 2023, at approximately 1:15 p.m., the Nursing Home Administrator confirmed that the facility did not provide agency nurses, Employees 2 and 3 training on the prohibition of all forms of abuse, neglect, and exploitation prohibition and the specifics of the facility's abuse prohibition policies and procedures. 28 Pa. Code 201.20(b)(d) Staff development 28 Pa Code 201.18 (e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights 395249 Page 15 of 15