Inspection·September 12, 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 Based on observation, clinical record review, and interviews with staff and residents, it was determined that the facility failed to provide dependent residents with activities of daily living assistance for three of five residents reviewed (Residents 2, 3, and 4). Residents Affected - Some Findings include: Clinical record review for Resident 2 revealed a plan of care developed by the facility to address his deficits with performing activities of daily living (initiated October 14, 2022). Interventions included in the plan of care noted that Resident 2 requires supervision/cueing for personal hygiene. Observation of Resident 2 on September 12, 2024, at 10:53 AM revealed several days of beard growth on his face. Interview with Resident 2 on the date and time of the observation revealed that staff shave him because he cannot see what he is doing to do it well. Resident 2 stated that he could not remember, but he may have had shaving assistance with his shower on Monday. Resident 2 stated that although his showers are scheduled for Mondays and Thursdays, he had a shower yesterday (Wednesday). Resident 2 stated that he was not sure why staff provided him shower assistance on a Wednesday; but believed, maybe they (staff) were trying to get ahead of the curve. Resident 2 confirmed that staff did not provide him with shaving assistance with his shower yesterday. Clinical record review for Resident 3 revealed a plan of care developed by the facility to address Resident 3's urinary incontinence and history of recurrent urinary tract infections. Interventions included in the plan of care instructed staff to adjust toileting times to meet Resident 3's needs, prompt and assist with toileting upon rising, before and after meals, before bed, and two to three times on overnight shift, and as needed; provide assistance with toileting, and provide incontinence care as needed. A plan of care initiated by the facility on January 15, 2019, to address Resident 3's deficits to perform activities of daily living included interventions that instructed staff to assist with daily hygiene, grooming, dressing, oral care, and eating as needed. Task List documentation (electronic documentation completed by nurse aide staff upon completion of activities of daily living tasks) dated July, August, and September 2024, for Resident 3 revealed that staff did not document the provision of oral care (scheduled for the day shift and evening shifts) as follows: July 2024, on seven occasions August 2024, on five occasions September 2024, on four occasions (dated September 1 through 11, 2024) (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: 395396 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 395396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook South 101 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)