Health inspection·August 1, 2023

F 0726 28 Pa Code 201.20(a) Staff development Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders for medications were followed, resulting in a significant medication error for one of 15 residents reviewed (Resident CR1). Residents Affected - Few Findings include: Closed clinical record review for Resident CR1 revealed that he was admitted to the facility on [DATE], due to acute osteomyelitis (bone infection) of the foot and ankle. Resident CR1 was discharged to home on [DATE]. A 5-day Medicare MDS (MDS, Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated [DATE], for Resident CR1 revealed the resident had a BIMS (BIMS, Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of 13-15 indicates intact cognitive response) of 15. A physician's order for Resident CR1 dated [DATE], revealed the nurse was to administer Oxycodone (a narcotic medication to treat severe pain) 5 mg (milligrams) every four hours as needed for pain for 14 days (last dose to be given [DATE]). Review of a witness statement dated [DATE], provided by Resident CR1, and written by the Nursing Home Administrator, revealed that the resident asked for a pain pill. The resident indicated that he had no idea what he was given but he took it and went back to sleep. He thought it was white. Review of a witness statement dated [DATE], provided by Employee 1, registered nurse, revealed that the nurse gave Resident CR1 an Oxycodone. The nurse indicated checking the narcotic book to see if was too soon to give the resident the medication and it wasn't, so it was given to him. Employee 1 indicated the on-coming nurse had pointed out that the medication was expired. Review of the Individual Patient Controlled Substance Administration Record for Resident CR1 revealed that Employee 1 signed the form as administering the Oxycodone 5 mg on [DATE], at 12:30 AM. Clinical record review for Resident CR 1 revealed no documentation in the nursing progress notes that the resident complained of pain and was administered Oxycodone. There was no documentation that the physician was notified of the resident receiving the Oxycodone or was assessed for side effects of the medication. The surveyor requested the facility's medication error report (a facility report regarding the medication error for the purposes of improving resident safety and outcomes by learning what went wrong when errors do occur and preventing reoccurrence) on [DATE], at 10:00 AM. The Director of Nursing indicated that there was no medication error report; however, she talked with the LPN (licensed practical nurse) who she felt should have destroyed the medication, so it was no longer in the medication cart. The surveyor was later provided a statement from the Director of Nursing. This statement was written and signed by the Director of Nursing on [DATE], indicating that she addressed to an LPN the importance of a narcotic to be destroyed when the orders are discontinued to prevent mistakes. The nurse verbalized understanding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 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 395364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook North 300 Leader Drive Williamsport, PA 17701 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident CR1 received Oxycodone, which was not a physician ordered medication resulting in a significant medication error. During an interview with the Nursing Home Administrator and Director of Nursing on [DATE], at 1:00 PM it was confirmed that Employee 1 was to review the MAR to determine current ordered medication prior to administration which resulted in the resident receiving a medication that was not ordered. It was also confirmed that a medication error report was not completed and therefore education to the entire nursing staff was not completed to prevent recurrence. The Nursing Home Administrator acknowledged that staff in addition to the licensed practical nurse should have been educated on destroying the medication once it was discontinued. 28 Pa. Code 211.12(d)(1)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 4 of 4