Inspection·September 19, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and resident and staff interview, it was determined that the facility failed to assist dependent residents with bathing, grooming, and dressing care for four of seven residents reviewed (Residents 1, 3, 5, and 7). Residents Affected - Some Findings include: Observation of Resident 1 on September 19, 2024, at 8:50 AM revealed that his shirt was soiled with dried stains. Interview with Resident 1 at this time revealed staff only change his shirt on his shower days. Resident 1 stated he receives a bed bath on Tuesdays and Fridays. Further observation of Resident 1 revealed a lot of facial hair. Resident 1 stated that he prefers to be clean shaven but is unable to shave himself due to not getting out of bed, having no mirror, and his poor eyesight. Resident 1 stated that staff refuse to shave him and tell him he can do it himself. Clinical record review for Resident 1 revealed his most recent MDS (Minimum Data Set, an assessment completed at specific interval to determine care needs) dated August 28, 2024, noted staff assessed him as requiring substantial/maximum assistance for upper body dressing, and he was dependent on staff for personal hygiene (including shaving). Clinical record for Resident 3 revealed her preference for bathing is to receive a shower on Mondays and Thursdays. Review of Task documentation (electronic system of nurse aide documentation of activities of daily living care) for the last 30 days revealed that Resident 3 received two showers on August 22, and September 16, 2024. Staff only documented one time that Resident 3 refused a shower. Review of Resident 3's most recent MDS dated [DATE], revealed she requires substantial/maximum staff assistance for bathing. Clinical record review for Resident 5 revealed her preference for bathing is to receive a shower on Wednesdays and Saturdays. Review of Task documentation for the last 30 days revealed that Resident 5 received two showers on September 7 and 11, 2024. Staff only documented two times that Resident 5 refused a shower. Staff documented NA (not applicable) three times in the last 30 days. Review of Resident 5's most recent MDS dated [DATE], revealed she requires substantial/maximum staff assistance for bathing. Clinical record review for Resident 7 revealed her preference for bathing is to receive a shower on Tuesdays and Fridays. Review of Task documentation for the last 30 days revealed that Resident 7 only received one shower in the last 30 days on September 6, 2024. The facility failed to provide assistance for bathing, dressing, and personal hygiene for residents (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 2 Event ID: 395364 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 09/19/2024 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)