Health inspection·November 16, 2023

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on review of select facility polity, the minutes from Resident Council Meetings and grievance logs and resident and staff interviews, it was determined that the facility failed to demonstrate prompt action to resolve resident grievances raised at resident group meetings and keep the residents apprised of the status of the facility's decisions and efforts toward grievance resolution. Residents Affected - Some Findings include: A review of the minutes from the Resident Council Meeting held during August 2023, revealed that 23 residents attended the meeting. During that meeting, the residents voiced concerns about nurse aides coming into their rooms and shutting off their call bells without meeting the needs of the residents for assistance. There was no documented evidence that the facility had addressed this concern. A review of the minutes from the Resident Council Meeting held during September 2023, revealed that 21 residents attended the meeting. During that meeting, the residents voiced the same concerns about the timeliness of assistance provided after ringing their call bells. There was no documented evidence that the facility had addressed this concern. Review of the facility's log of grievances received from residents from August 2023 to the time of the survey ending November 16, 2023, revealed that the facility did not include the complaints and concerns voiced at Resident Council meetings as grievances lodged with the facility. Interview on November 16, 2023, at 1:50 PM with the Director of Nursing confirmed there was no documented evidence the resident grievances brought to facility's attention were addressed and resolved timely. 28 Pa. Code: 201.18 (e)(1) Management. 28 Pa. Code: 201.29 (a) Resident Rights. Page 1 of 4 395249 395249 11/16/2023 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 - 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. 395249 Page 2 of 4 395249 11/16/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

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 395249 Page 3 of 4 395249 11/16/2023 Edenbrook at Hampton 1548 Sans Souci Parkway Wilkes Barre, PA 18702

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. 395249 Page 4 of 4