Health inspection·February 28, 2024

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to promptly act upon known risk factors, including immobility, for pressure sore development and timely implement individualized measures to prevent pressure sore development and promote healing for one of six residents sampled with pressure sores (Resident 1). Residents Affected - Few Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk. ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. Review of a facility policy entitled Skin Integrity indicated that the purpose was to provide a systemic approach and monitoring process for skin and decrease pressure ulcer formation by identifying those residents who are at risk and developing interventions. Provide guidelines for optimal skin care to promote healing to residents with all identified alterations in skin integrity including surgical incisions. If an identified risk is present the interventions will be documented in the baseline plan of care and or comprehensive care plan. Initiation of positioning schedule to meet individual resident needs and minimize concentrated pressure to skin. Positioning devices such as pillows or foam wedges are recommended to keep bony prominences from direct contact with one another, consider adding therapy screen for any positioning recommendations. Cleansing/Incontinent care - rinse with warm water pat dry do not massage bony prominences, may apply moisture barrier cream, or follow center incontinence protocol. Promote activity level, mobility, and range of motion as appropriate. Review of current facility policy entitled Pressure Ulcer Treatment indicated that the purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Review the resident's care plan to assess for any special needs of the resident. Notify the supervisor if the resident refuses the procedure and interventions and report (continued on next page) 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 Page 1 of 6 Event ID: 395249 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 02/28/2024 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)