Health inspection·February 2, 2024

F 0677 wet, or was not permitted to be transferred due to recent surgery. Level of Harm - Minimal harm or potential for actual harm The above information regarding Resident CR1 was reviewed with the Nursing Home Administrator and Director of Nursing on February 2, 2024, at 3:05 PM. The Director of Nursing confirmed that there was no documentation as to why Resident CR1 did not have a bed bath on January 9 and January 26, 2024, which resulted in the resident not being bathing for seven days on two occasions. Residents Affected - Some 483.24 (a)(2) Necessary services for ADL's Previously cited 6/16/23 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 2 of 8 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 02/02/2024 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 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 clinical record review and staff interview, it was determined that the facility failed to provide necessary treatment and services to promote healing of a pressure ulcer for one of two residents reviewed (Resident CR1). Residents Affected - Few Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility from the hospital on December 15, 2023, after a fall and having right hip surgery. Resident CR1 had a change in condition and was admitted to the hospital on [DATE]. Resident CR1 was not in the facility at the time of the survey. Review of a nursing admission assessment dated [DATE], for Resident CR1 revealed that a Stage I (non-blanchable redness of a localized area over a bony prominence) pressure ulcer measuring 0.3 cm (centimeters) length x 0.2 cm width x 0.0 cm depth was observed on the resident's buttocks. Review of a wound care consultant assessment dated [DATE], revealed the consultant identified this pressure ulcer as a Stage I over the sacrum (the large flat bone in the lower part of the spine) that measured 1.3 cm length x 0.3 cm width x 0.5 cm depth. Review of physician orders for Resident CR1's pressure ulcer dated December 20, 2023, were for the nurse to cleanse the sacrum with acetic acid 0.25% (solution to prevent wound infections), apply barrier cream (a cream used to provide skin protection from urine and feces), and apply a dry padded dressing every day and as needed. (Note that the wound consultant notes were not available immediately, which accounts for the treatment not starting on the date the resident was seen). Review of the TAR (treatment administration record, form for documenting the treatment provided as ordered by the physician) for Resident CR1 dated December 21 through December 27, 2023, revealed no initials in the date of December 24, 2023. Interview with the Director of Nursing on February 2, 2024, at 3:00 PM revealed if the treatment was not signed for this indicated the treatment was not provided. Review of a wound care consultant assessment dated [DATE], revealed the consultant identified this pressure ulcer as a Stage I that measured 1.3 cm length x 0.3 cm width x 0.1 cm depth. Review of a wound care consultant assessment for Resident CR1 dated January 2, 2024, revealed the pressure ulcer declined to a Stage II (a partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer), that measured 1 cm length x 0.3 cm width x 0.1 cm depth. Review of the TAR for Resident CR1 dated December 28, 2023, through January 10, 2024, revealed the nurse was to cleanse the sacrum with acetic acid 0.25 %, apply collagen fibers (a special fiber that promotes healing and growth of new skin), zinc (cream formulated for healing and protecting the skin), and apply a dry padded dressing every day and as needed. Review of the TAR revealed no initials in the dates of December 30, 2023, and January 4, 5, and 10, 2024, indicating the treatment was not provided on those dates. Review of a wound care consultant assessment for Resident CR1 dated January 9, 2024, revealed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 3 of 8 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 02/02/2024 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few pressure ulcer declined to a Stage III (full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed, may include undermining and tunneling) that measured 2 cm length x 4 cm width x 0.1 cm depth. Review of the TAR for Resident CR 1 dated January 11 through 16, 2024, indicated the nurse was to cleanse the ulcer with Normal Saline Solution (fluid like normal body fluid), pat dry, apply collagen fibers, zinc, and a dry padded dressing daily and as needed. The TAR indicated that the resident received the physician ordered treatment daily as ordered. Review of a wound consultant assessment for Resident CR 1 dated January 16, 2024, revealed the sacral wound healed. The facility failed to provide physician ordered treatments to Resident CR1's pressure ulcer on the above dates to promote healing. During an interview with the Director of Nursing on February 2, 2024, at 3:00 PM confirmed the above findings. 28 Pa Code 211.10(d) Resident care policies 28 Pa Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 4 of 8 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 02/02/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 observation, clinical record review, and staff interview, it was determined that the facility failed to ensure safety interventions were in place and that a fall was investigated for one of three residents with falls (Resident CR1). Findings include: Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility from the hospital on December 15, 2023, after a fall and right hip surgery was performed. Resident CR1 had a change in condition and was admitted to the hospital on [DATE]. Resident CR1 was not in the facility at the time of the survey. Documentation indicated that the resident planned to return to the facility after hospitalization. Review of facility documentation for Resident CR1 revealed the staff heard the resident yelling and heard a fall. The staff immediately responded and found the resident laying on the left side with the head against the wall. The RN (registered nurse) assessed Resident CR1 and observed the surgical site bleeding (from right hip surgery) with the right foot rotated. The resident was sent to the emergency room for evaluation. Review of a nursing progress note dated December 26, 2023, at 11:10 PM revealed the resident was alert with confusion all day. The resident was non-compliant with transfers, denies pain or discomfort, and vital signs were stable. The resident was transferred to the emergency department by emergency medical technicians. Review of a nursing progress note dated December 27, 2023, at 3:50 AM revealed the resident returned from the emergency department with a urinary tract infection and scans of leg and hip were negative (indicating no fracture). Closed clinical record review for Resident CR1 revealed that there was no nursing documentation pertaining to the fall, including an assessment of the resident, for the fall that occurred on December 26, 2023. During an interview with the Director of Nursing on February 2, 2024, at 11:00 AM there was no investigation into the fall, including obtaining witness statements from staff caring for the resident prior to and at the time of the fall. The Director of Nursing provided the surveyor with a copy of Resident CR1's care plan. Review of the care plan dated December 15, 2023, indicated that the resident was a high risk for falls related to impaired cognition (thinking) resulting in lack of safety awareness and a recent hip fracture. A fall intervention was added on December 27, 2023, for the resident to have a perimeter defining mattress (the mattress is elevated on the sides creating a raised rail within the mattress). Observation of Resident CR1's room on February 2, 2024, at 11:50 AM revealed the resident's personal belongings present and a bed with a pressure reducing mattress. A perimeter defining mattress was not on the bed. During a concurrent interview with Employee 1, licensed practical nurse, it could not be confirmed that this was a perimeter defining mattress as the employee was not certain. The surveyor went to the therapy department and Employee 2, occupational therapy, came to the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 5 of 8 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 02/02/2024 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 0689 room. Employee 2 confirmed that the mattress was not a perimeter defining mattress. Level of Harm - Minimal harm or potential for actual harm The facility failed to provide a fall prevention device for Resident CR1 as outlined in the resident's plan of care. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 6 of 8 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 02/02/2024 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 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Based on clinical record review and resident and staff interview, it was determined that the facility failed to secure transportation for outside services for one of two residents reviewed for transportation needs (Resident 6). Findings include: In an interview with Resident 6 on February 2, 2023, at 11:55 AM revealed the resident was visibly upset. Resident 6 indicated he was scheduled to receive an infusion outside the facility on January 25, 2024, and that date came, and he was told transportation wasn't available and the appointment had to be rescheduled for Monday, January 29, 2024. On Monday, the resident stated he was again told the facility could not get him transportation, and the appointment was changed to February 2, 2024, the day of the interview. Staff got him up at 6:30 in the morning and he was all ready to go and found out at 8:30 AM that he again did not have transportation and the appointment was rescheduled for February 7, 2024. The resident stated he went to talk to administration and was given the response that because he was in an electric wheelchair it wasn't easy to get him transportation. Resident 6 indicated he receives infusions for a diagnosis of Multiple Sclerosis (a chronic diseases of the central nervous system) every six months, and there is only a 14-day window to receive the infusion, and now he was scheduled on February 7, 2024, with only one day left in the 14-day period due to all the cancellations. Review of Resident 6's clinical record revealed an appointment consultation form dated July 27, 2023, noting the resident was at an appointment for his Multiple Sclerosis and received a medication infusion. Further review of Resident 6's clinical record revealed an after visit summary report present in Resident 6's clinical record dated December 18, 2023, indicating the resident attended a neurology appointment for his Multiple Sclerosis on that day. The after-visit summary included information for an appointment on January 25, 2024, at 9:00 AM for an infusion. Review of Resident 6's physician's orders also revealed an order dated December 18, 2023, that the resident has an appointment for treatment with infusion on January 25, 2024, at 9:00 AM at hematology/oncology at the hospital. The order was discontinued on January 23, 2024, with the comment of need new appointment, there was no documentation to indicate why. In an interview the Nursing Home Administrator (NHA) on February 2, 2024, at 2:05 PM she indicated the transportation company cancelled on the facility and there was no way to find the resident new transportation on short notice. The NHA concurrently placed the surveyor on a conference call with the administrator and a representative from one of the facility's transportation companies. The representative stated the transportation company had to cancel the transport for Resident 6 on Monday, January 29, 2024, because the drivers were sick, there were no replacements, and stated they called the facility on February 1, 2024, to let the transportation scheduler at the facility know they could not take the resident on February 2, 2024, due to a miscommunication. The transport company thought the appointment was local and did not have anyone to take the resident farther. The representative stated Resident 6 was now scheduled for February 7, 2024, and they would make sure there were extra people scheduled so that the resident would make the appointment. The representative was asked if they cancelled Resident 6's transport for an appointment on January 25, 2024, the date of the original (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 7 of 8 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 02/02/2024 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 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appointment, and the representative stated they were not. The representative stated she would look for any communication where the facility may have requested transport for Resident 6 where the company would have told them they couldn't do the transfer but did not see any communication at the time of the conference call. As 2:25 PM the NHA indicated she had just received a text message from the representative at the transfer company and they indicated the facility had contacted them about transporting Resident 6 to the appointment on January 25, 2024, but they were not able to take the resident. The Nursing Home Administrator stated it was too short of notice to arrange transport for the resident with another provider. There was no evidence as to what date the initial request was made to this transport company regarding Resident 6's appointment on January 25, 2023, and the representative indicated there was no transport ever scheduled for them to transport the resident on January 25, 2023, that the transport company cancelled. Per the record review noted above, the facility was aware of the need to transport Resident 6 to the January 25, 2024, appointment on December 18, 2023. There was no evidence to indicate the facility secured transportation for the appointment on January 25, 2024, after knowing about the appointment greater than 30 days in advance, or that the transport company cancelled a scheduled transport for January 25, 2024, for Resident 6, only that the order dated December 18, 2023, for the appointment, was discontinued on January 23, 2024, indicating a new appointment was needed. Resident 6 missed infusion appointments on January 25, 29, and February 2, 2024. 28 Pa. Code 201.21(c) Use of outside resources 28 Pa. Code 211.12(d)(3) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395364 If continuation sheet Page 8 of 8