Inspection·November 16, 2023

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 observations and staff interview, it was determined that the facility failed to maintain a clean and orderly environment in resident areas on three of three resident units (A hall, B hall, and C hall Nursing Units) Findings include: Observations on November 16, 2023, at 9:30 AM of the C hall Nursing Unit revealed the following: In resident Room C17 the molding was peeling off from the wall. There was a hole in the wall in the bathroom. Feces was observed on the toilet. The floor next to the toilet was wet and had a black substance around the toilet. A strong odor of urine was present. The bathroom floor was sticky. Observation in the central shower room revealed a hole in the wall outside the door that was attempted to be patched but the patch was also damaged. There were holes in the wall in the shower room along with sticky drips running down the wall with hair stuck to the wall. There were missing heat lamp lights in the shower room. The tile in the bathroom was cracked and broken. There was hair in the shower drain. [NAME] spots and a black substance were observed the shower curtains. Dirt and debris was observed on the floor of the hallway. A dried brown substance was observed on the floor. Gouges and black streaks were observed on the wall. In resident room C1 urinals and bed pans were observed on the bathroom floor. There were gouges and black streaks on the walls in the resident room and a used disposable glove lying on the floor. Observations on November 16, 2023, at 9:48 AM of the A hall Nursing Unit revealed the following: The central shower room curtains were dirty with brown spots and a black substance on the bottom. Holes were observed in the walls. There was hair and debris in the shower drains. The heat lamps were not functioning. The close in resident Room A11 closet was chipped and the backing was coming off the closet. The wallpaper was peeling off the wall. The molding was peeling away from the wall. The wallpaper was torn in resident Room A9. Observations on November 16, 2023, at 9:57 AM of the B hall Nursing Unit revealed the following: In resident Room B15 dirt and debris was observed on the floor. The was cracked and chipped spackle on the walls. Bed 2 in the room had a broken controller. Used disposable gloves and debris were observed on the floor in resident room B6. The heat lamps in the central shower room did not work. Sticky drip spots were observed on the walls. There was cracked tile in the shower. There was a rust over the shower storage hanger containing a handheld shower head that was leaking. The shower curtains appeared dirty with brown and black spots. A brown-fecal like substance was observed on the shower chair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395249 If continuation sheet Page 2 of 4 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 395249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook at Hampton 1548 Sans Souci Parkway 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 0584 Gouges were observed on the walls of the hallway. Level of Harm - Minimal harm or potential for actual harm In resident Room B2 the molding was peeling away from the walls. Residents Affected - Some Interview with the Director of Nursing on November 16, 2023, at approximately 1:15 PM confirmed the facility is to be maintained daily to provide a clean, orderly and sanitary environment for the residents. 28 Pa. Code 201.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395249 If continuation sheet Page 3 of 4 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 395249 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook at Hampton 1548 Sans Souci Parkway 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on clinical record review and staff and resident interview, it was determined that the facility failed to include the resident's preferences for showers/bathing on the comprehensive care plan of one resident out of five reviewed (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility July 14, 2023, with diagnoses to include heart disease. Review of the admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated August 3, 2023, revealed that the resident was cognitively intact, with a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 15 and required extensive assist with ADLs including bathing. During an interview with Resident 1 on November 16, 2023, at approximately 9:20 a.m., the resident stated she had never been asked her preference for shower times and days to be showered. A review of Resident 1's comprehensive care plan, conducted on November 16, 2023, revealed that the resident's current care plan did not address resident preferences for bathing/showering. Interview with the Director of Nursing (DON) on November 16, 2023, at approximately 1:30 PM, confirmed the absence of shower preferences on Resident 1's care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395249 If continuation sheet Page 4 of 4