Inspection·January 24, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and safe environment on four of four nursing units (North, South, East and West, Residents 85, 56, 68, 14, 39, and 50 ). Findings include: An observation of Resident 85 on January 21, 2025, at 10:28 AM revealed the resident was in bed. An enteral feeding pump was observed hanging from the pole beside the resident's bed, not in use. The feeding pump was observed to have several spots of dried brown liquid splatter/spills on the exterior of the feeding pump. There was no enteral feeding bag/container hanging at the time of the observation. Resident 85's observation of the feeding pump was reviewed with the Director of Nursing on January 22, 2025, at 2:30 PM. An observation of Resident 56 on January 21, 2025, at 11:01 AM revealed the resident was in bed. An enteral feeding pump and bag was observed hanging from a pole beside the resident's bed. The feeding pump was observed to have several spots of dried brown liquid splatter/spills on the exterior of the feeding pump, the pole, and the bagged supplies hanging from the pole. The above findings for Resident 56's feeding tube feed were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on January 22, 2025, at 2:12 PM. Observation of the [NAME] Nursing Unit on the following dates and times revealed the following: On January 21, 2025, at 11:30 AM there was a strong odor of urine in Resident 68's bathroom. On January 22, 2025, at 11:47 AM there was a strong odor of urine in Resident 68's room and the bathroom. At 12:02 PM there was a strong odor of urine in Resident 14's room. On January 23, 2025, at 11:56 AM there was a strong odor of urine in Resident 68's room. On January 24, 2025, at 10:57 AM there was a faint odor of urine in Resident 14's room. The surveyor reviewed this information during an interview with the Nursing Home Administrator and Director of Nursing on January 23, 2025, at 2:45 PM. Observation of Resident 39's room on January 22, 2025, at 10:13 AM revealed a strong urine smell, and the floor was dirty from his bed to the area at the bottom of his roommates bed. The wall to the left of the doorway was dirty. There were two night stands right inside the door to the left with an unorganized pile of stuff on top to include: briefs, clothes, books, CDs, O2 equipment, and Eucerin cream (used to treat dry skin). The first nightstand had the handle missing from the top drawer. The second nightstand had a broken handle hanging down from the second drawer. The wall to the right of the bed (when looking at the bed) and adjacent to the bathroom, was all marred and the paint was peeled near the bottom of the wall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 2 of 24 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 01/24/2025 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)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation of Resident 50's room on January 24, 2025, at 10:45 AM revealed the cove base coming off the wall directly behind the head of Resident 50's bed. There were crumbled pieces of the wall on the floor that appeared to have come from the area where the cove base was missing. The Nursing Home Administrator and Director of Nursing were made aware of the concerns in Resident 39 and 50's rooms on January 24, 2024, at 11:30 AM. 483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment Previously cited 2/16/24, and 8/6/24 28 Pa. Code 201.14(a) Responsibility of licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 3 of 24 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 01/24/2025 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)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, staff interview, and review of facility investigation documentation, it was determined that the facility failed to thoroughly investigate a resident's injury of unknown origin for one of two residents reviewed for abuse (Resident 42). Residents Affected - Few Findings include: Clinical record review for Resident 42 revealed a progress note dated December 30, 2024, at 1:16 PM that indicated the nurse was made aware of Resident 42 having a bruise on the right side of her face that measured 3 centimeters (cm) x 2 cm and was dark bluish and purplish in color. The bruise was on the outside of the right eye. The note indicated that Resident 42 is combative with care and staff were educated to walk away when performing care if the resident becomes combative to avoid self-inflicted wounds. Further clinical record review revealed that there was no follow-up progress notes related to the event until January 22, 2025, at 5:49 PM after the surveyor inquired about event reports related to Resident 42 in a meeting on January 22, 2025, at 3:01 PM with the Director of Nursing. The note indicated that the registered nurse concluded her investigation and believed that Resident 42's bruise was consistent with her aggressively knocking her glasses off her face while having behaviors during care. The note also indicated that the staff were educated. Review of the facility's investigation into the event revealed that they did not obtain witness statements from staff related to how the injury may have occurred and there was no evidence of staff education. Interview with the Director of Nursing on January 23, 2025, at 2:55 PM revealed that she did not have witness statements from staff related to how the bruise may have occurred, or evidence that the staff were educated on interventions to implement when Resident 42 became combative and aggressive with care. The facility failed to thoroughly investigate Resident 42's injury of unknown origin. 483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Previously cited 5/22/2024. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 4 of 24 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 01/24/2025 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)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected a resident's status for one of 21 residents reviewed (Resident 52). Residents Affected - Few Findings include: Clinical record review for Resident 52 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 6, 2024, that facility staff assessed Resident 52 as receiving an anticoagulant medication during the last seven days in the assessment period. Further clinical record review revealed no evidence that Resident 52 received an anticoagulant medication during the assessment period for the MDS noted above. Interview with the Director of Nursing on January 23, 2025, at 2:31 PM confirmed that Resident 52's November 6, 2024, MDS was coded in error regarding receiving an anticoagulant medication. 28 Pa. Code 211.5(f)(ix) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 5 of 24 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 01/24/2025 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)

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 clinical record review and staff interview, it was determined that the facility failed to provide activities of daily living (ADL) for two of five residents reviewed (Resident 65 and 89). Residents Affected - Some Findings include: Clinical record review for Resident 65 revealed that the facility completed a significant change MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on November 25, 2024, which indicated that it was somewhat important that they choose between a tub bath, shower, bed bath, or sponge bath. The MDS also identified that they were dependent on staff for a shower and to bathe themself. Review of Resident 65's task documentation (documentation where staff indicate completion of ADL care) revealed that since June 29, 2023, staff was to complete ADL - Bathing (bed bath) during the day shift on Tuesdays and Saturdays. Review of Resident 65's task documentation revealed that there was documentation that indicated staff provided the following showers to Resident 65: October 5 and 29, 2024 November 12, 19, 26, and 30, 2024 December 3, 7, and 31, 2024 January 7, and 11, 2025 Further review of Resident 65's task documentation revealed that staff documented RR (resident refused) or did not document that bathing was completed on the following dates: October 8, 2024 November 2 and 23, 2024 December 14, 17, and 21, 2024 January 18, 2025 There was no documentation that indicated staff re-approached, re-addressed bathing, or provided Resident 65 the opportunity to bathe the next shift or following day. Further review of Resident 65's task documentation revealed that staff indicated No they did not cleanse Resident 65's hair on bathing days or did not document completion of cleansing Resident 65's hair on the following dates: October 5, 2024, day shift October 8, 2024, evening shift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 6 of 24 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 01/24/2025 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)

F 0677 November 2, 2024, evening shift Level of Harm - Minimal harm or potential for actual harm November 23, 2024, day shift December 21, 2024, evening shift Residents Affected - Some December 24, 2024, day and evening shift January 4, 7, and 18, 2025 Further review of Resident 65's task documentation revealed that staff documented RR (resident refused) or did not document that hair cleansing was completed on the following dates: October 5, 2024, evening shift October 8, 2024, day shift October 22, 2204, day and evening shift November 2, 2024, day shift November 23, 2024, evening shift December 21, 17, and 21, 2024 January 18, 2025 There was no documentation that indicated staff re-approached, re-addressed cleansing Resident 65's hair, or provided Resident 65 the opportunity to cleanse their hair the following day. Observation of Resident 65 on January 22, 2025, at 11:46 AM and January 23, 2025, 2:07 PM revealed that their hair was disheveled. The surveyor reviewed the above information during an interview with the Director of Nursing on January 24, 2025, at 8:57 AM Clinical record review for Resident 89 revealed that the facility admitted him on March 23, 2024, with diagnosis of dementia with behavioral disturbances and adult failure to thrive. Clinical record review for Resident 89 revealed current task documentation that he was independent to requiring transfer assistance and at times requires physical assistance with bathing/showers and personal hygiene. Review of Resident 89's task documentation revealed that staff were to complete his showers on Sundays and Thursdays during the day shift. Review of Resident 89's task documentation for November 2024, revealed that there was documentation that indicated staff provided him with a shower or bed bath on November 10, and November 21, 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 7 of 24 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 01/24/2025 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Review of Resident 89's task documentation for December 2024, revealed that there was documentation that staff provided him with a shower or bed bath on December 8, 2024. Review of Resident 89's task documentation for January 1-19, 2025, revealed that there were no documented showers for him during that time period. Residents Affected - Some Review of Resident 89's shower documentation for November 2024, revealed that he refused his shower on November 3, 7, 14, 17, 24, and 28, 2024. Review of Resident 89's shower documentation for December 2024, revealed that he refused his shower on December 1, 5, 12, 15, 19, 22, and 26, 2024, with no documentation on December 29, 2024. Review of Resident 89's shower documentation for January 1-19, 2025, revealed that he refused his shower on January 2, 5, 9, 12, and 16, with no documentation on January 19, 2025. There was no documentation that indicated staff re-approached, re-addressed bathing, or provided Resident 89 the opportunity to bathe the next shift or following day. Review of Resident 89's care plan revealed no interventions related to him refusing baths or showers. The surveyor reviewed the above information during an interview with the Director of Nursing on January 23, 2025, at 3:08 PM. 483.24(a)(2) Adl Care Provided for Dependent Residents Previously cite 9/12/24, 5/22/24, and 2/16/24 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 8 of 24 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 01/24/2025 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to ensure the highest practical care related to consultant recommendations for one of 21 residents reviewed (Resident 93). Residents Affected - Few Findings include: Observation and interview with Resident 93 on January 21, 2025, at 10:51 AM revealed Resident 93 complained of a cold hand. Observation of his right hand revealed he had no grasp, and his fingers were partially contracted. He stated that he sits on his hand to try and warm up his hand and straighten his fingers. Resident 93 stated that he went to see a specialist about his hand. Review of Resident 93's clinical record indicated he saw a plastic surgeon on January 13, 2025, due to pain and stiffness in his right hand. The physician progress note indicated with some exercise Resident 93's range of motion improved. The physician noted that the facility stopped doing occupational therapy even though he was improving. The physician recommended warm soaks twice a day and a need to resume hand therapy. Further review of Resident 93's clinical record revealed no documentation that the facility implemented the physician's recommendations. Interview with the Director of Nursing on January 24, 2025, at 11:06 AM confirmed these findings and stated the facility implemented the physician's recommendations after the surveyor's questioning. 483.25 Quality of Care Previously cited deficiency 2/16/24 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 9 of 24 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 01/24/2025 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **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 services to maintain or improve a resident's range of motion (ROM) and mobility for three of seven residents reviewed (Residents 42, 65, and 70). Findings include: Clinical record review for Residents 65 revealed a current therapy restorative referral dated November 29, 2024. Therapy staff indicated nursing staff should provide seated AROM/AAROM (active and active assisted range of motion, movement of the body to maintain a resident's ability) one to two times daily for their LAQ's (bilateral anterior quadriceps, upper leg muscles) marches, heel to toes, hip abduction (legs move away from the body's midline), adduction (legs move towards the body's midline), and pillow squeezes. Review of Resident 65's task documentation revealed that nursing staff did not implement the AROM/AAROM the restorative nursing program until December 6, 2024, day shift. There was no documentation that staff completed or indicated No for Resident 65's AROM/AAROM restorative nursing program on the following dates: December 6. 15, 25, and 30, 2024 January 8, 13, 18, and 19, 2025 The surveyor reviewed the above information on January 24, 2025, at 11:44 AM with the Director of Nursing. Clinical record review for Resident 42 revealed a Minimum Data Set (MDS, an assessment completed by the facility at intervals to determine care needs of the resident) assessment dated [DATE], that indicated she had an impairment on one side of her upper and lower extremities. Further clinical record review revealed no evidence that Resident 42 was receiving a ROM program. Review of Resident 42's physical therapy discharge information dated December 23, 2024, revealed that a restorative ROM program was established, and staff were trained for Resident 42 to have AROM/AAROM to bilateral lower extremities. Review of her occupational therapy discharge information dated December 20, 2024, revealed that a ROM program was established for her right upper extremity. Resident 42 was also to have a splint brace program for a carrot splint (a device placed in hand to prevent contractures) to be placed in her right hand at all times except for meals and activities of daily living. A restorative nursing program instruction form from physical therapy was sent to nursing on December 24, 2024, outlining the instructions for the program that was to be completed with Resident 42 related to her bilateral lower extremities. The program was never initiated until January 22, 2025, after the surveyor brought it to the attention of the Director of Nursing (DON) on the same date at 3:00 PM. The Nursing Home Administrator and the DON were made aware of the issues above related to Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 10 of 24 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 01/24/2025 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)

F 0688 42's ROM and splint programs on January 23, 2025, at 3:00 PM. Level of Harm - Minimal harm or potential for actual harm Clinical record review for Resident 70 revealed an MDS assessment dated [DATE], that indicated he had a limited ROM on one side of his upper and lower extremity. Further clinical record review revealed no evidence that he was receiving a ROM program. Residents Affected - Some Review of Resident 70's physical therapy summary dated December 23, 2024, revealed that a ROM program was established for AROM to his bilateral lower extremities. A restorative nursing program instruction form from physical therapy was sent to nursing on December 24, 2024, outlining the instructions for the program that was to be completed with Resident 70 related to his bilateral lower extremities. There was no evidence that the program was ever initiated. The Director of Nursing confirmed on January 24, 2024, at 8:54 AM that the ROM program for Resident 70 was never initiated. The facility failed to provide services to maintain or improve range of motion for Residents 42, 65, and 70. 483.25(c)(1)-(3) Increase/prevent Decrease In Rom/mobility Previously cited 9/12/24 and 2/16/24 28 Pa. Code 211.10(a)(c)(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 11 of 24 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 01/24/2025 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of three residents reviewed (Resident 43). Residents Affected - Few Findings include: According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag. Clinical record review for Resident 43 revealed a current physician's order for staff to provide oxygen at 5 liters per minute (LPM) via NC (nasal canula, tubing to deliver oxygen to the nose) continuously every day and evening shift for supplementary oxygen and BiPAP (pressurized non-invasive air ventilation via mask): oxygen 6 to 7 LPM at bedtime and as needed (PRN) for sleep apnea. Observation of Resident 43's oxygen concentrator on January 21, 2025, at 11:15 AM and January 22, 2025, at 11:52 AM and 3:20 PM revealed that their oxygen level was set at 9 LPM via NC and without humidification. Resident 43's BiPAP mask was unbagged and lying on the floor behind their oxygen concentrator during the January 21, 2025, observation and lying on their bedside stand during the January 21, 2025, observations. The surveyor reviewed the above information for Resident 43 during an interview with the Director of Nursing on January 22, 2025, at 3:20 PM. 483.25(i) Respiratory/tracheostomy Care and Suctioning Previously cited 2/16/24 28 Pa. Code 211.10 (c)(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: 395396 If continuation sheet Page 12 of 24 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 01/24/2025 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on review of facility documentation and staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care and assessment of residents with enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes for four of four employees reviewed for competencies (Employees 4, 5, 6, and 7). Findings include: A review of the facility documentation revealed that the facility had a total of 121 residents receiving medications, 10 residents with indwelling catheters (insertion of a tube into the bladder to remove urine), five residents with pressure ulcers, five residents with enteral tube feedings (device that allows liquid food to enter your stomach or intestine through a tube), and one resident with a tracheostomy (a surgical airway management procedure that consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea). A request for nursing staff competencies for enteral tube feeding, tracheostomy care, catheter care, medication administration, and dressing changes revealed the facility was unable to provide any competencies for Employees 4 (registered nurse, RN), 5 (RN), 6 (licensed practical nurse, LPN), and 7 (LPN). The findings were reviewed with the Nursing Home Administrator and Director of Nursing on January 24, 2025, at 9:03 AM. Further interview with the Director of Nursing on January 24, 2025, at 10:15 AM confirmed the facility could provide no documentation that ensured Employees 4, 5, 6, and 7 have specific competencies and skill sets to care for the residents' needs listed above. 28 Pa Code 201.20(a) Staff development FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 13 of 24 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 01/24/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review and staff interview, it was determined that the facility failed to maintain pharmacy recommendations or evidence pharmacy recommendations were addressed by the physician for three of five residents reviewed (Residents 23, 42, and 49). Findings include: Clinical record review for Resident 23 revealed a pharmacist monthly medication review note dated June 10, 2024, which indicated a medication review was completed for the resident and to see report for recommendation. There was no evidence of the pharmacist report of recommendations or a physician's response to a pharmacy recommendation for the date indicated. Interview with the Nursing Home Administrator and Director of Nursing on January 24, 2025, at 8:52 AM revealed the pharmacy recommendation for June 10, 2024, could not be located to determine if the physician addressed the recommendation. Clinical record review for Resident 49 revealed that the consultant pharmacist completed a medication review on November 10, 2024. There was no documentation what the consultant pharmacist recommended or that the physician or facility responded to the consultant pharmacist recommendations. This surveyor reviewed the above information during an interview with the Nursing Home Administrator on January 24, 2025, at 9:15 AM. Clinical record review for Resident 42 revealed a consultant pharmacist monthly medication review note dated June 10, 2024, which indicated a medication review was completed for the resident and to see report for recommendation. There was no evidence of the pharmacist's report of a recommendation or a physician's response to a pharmacy recommendation for the date indicated. The Nursing Home Administrator and the Director of Nursing confirmed on January 24, 2025, at 8:54 AM that they could not locate the pharmacy recommendation from June 10, 2024. 483.45(c)(4) Pharmacy review Previously cited 2/16/24, and 5/22/24 28 Pa. Code 211.9 (d)(k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 14 of 24 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 01/24/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for two of five residents reviewed for medication regime review (Residents 9 and 65). Findings include: Clinical record review revealed the facility admitted Resident 9 on January 16, 2023. Review of the consultant pharmacist's recommendation dated July 13, 2024, revealed Resident 9 has been receiving Buspar (medication used to treat anxiety) 10 milligrams (mg) three times a day and Cymbalta (antidepressant medication) 90 mg every day. The consultant pharmacist requested the facility consider an attempted dose reduction or trial discontinuation. Resident 9's physician agreed to change her Cymbalta to 60 mg every day on July 24, 2024. Further review of Resident 9's clinical record revealed the facility never decreased her Cymbalta to 60 mg until January 17, 2025. Interview with the Nursing Home Administrator and Director of Nursing on January 24, 2025, confirmed these findings indicating the facility did not follow through with the physician's response to Resident 9's July 13, 2024's, consultant pharmacist recommendation. Clinical record review for Resident 65 revealed the following physician orders: Ativan (Lorazepam) 0.5 mg by mouth (PO) every 8 hours as needed (PRN) for anxiety, ordered on August 27, 2024, and discontinued on August 31, 2024. There was no stop date identified for this PRN psychotropic medication. Ativan 0.5 mg PO every 8 hours PRN for anxiety for 14 Days, ordered on August 31, 2024, and discontinued on September 3, 2024. Ativan 0.5 mg PO every 8 hours PRN for anxiety for 28 Days, ordered on September 3, 2024, and discontinued on October 1, 2024. Ativan 0.5 mg PO every 8 hours PRN for general anxiety disorder (GAD), ordered on October 7, 2024, 11:00 AM and discontinued on October 7, 2024, shortly thereafter. There was no stop date identified for this PRN psychotropic medication. Ativan 0.5 mg PO every 8 hours PRN for GAD for 30 Days, ordered on October 7, 2024, and discontinued on November 6, 2024. Lorazepam 0.5mg PO once for anxiety PRN, one time only for anxiety/behaviors for 1 day, ordered on November 7, 2024, at 11:00 AM and discontinued on November 7, 2024, shortly thereafter. Lorazepam 0.5 mg PO every 8 hours PRN for GAD for 30 Days then re-evaluate, ordered on November 26, 2024, and discontinued on December 12, 2024. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 15 of 24 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 01/24/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Lorazepam 0.5 mg PO every 8 hours PRN for GAD for 90 Days, ordered on December 12, 2024, and currently active. Review of facility documentation revealed that staff initiated and re-ordered Resident 65's Ativan PRN medication on October 7, 2024. There was no documentation available that indicated Resident 65's physician, physician's assistant, or physician's assistant specializing in psychiatry saw them on October 7, 2024, to provide justification for the PRN Ativan. Review of Resident 65' behavior monitoring from August to December 2024, and January 2025, revealed staff documented behavior(s) on the following dates: August 23, 2024, evening shift August 27, 2024, day shift August 28, 2024, day and evening shifts August 31, 2024, day shift September 1, 4, 5, 10, 11, 21, 22, 28, and 29, 2024, day shift September 2, 14, 15, and 18, 2024, evening shift September 23, 2024, night shift October 7, 8. 13, 14, 15, 18, 20, 23, 25, and 26, 2024, day shift October 19, 20, and 29, 2024, evening shift November 1, 3, 8, 10, 12, 13, 14, 18, 20, 21, 22, 26, 28, 2024, day shift November 16, 20, and 23, 2024, evening shift November 7 and 26, 2024, night shift December 3, 8, 10, 16, 19, 21, 22, 24, 28, 2024, day shift December 4, 7, 9, 11, 12, 13, 15, 19, 22, 26, 27, and 31, 2024, evening shift December 16 and 29, 2024, night shift January 2, 3, 4, 5, 6, 9, 10, 13, 14, 21, 2025, day shift January 4, 6, 7, 12, 13, 15, 16, 18, and 19, 2025, evening shift January 23, 2025, night shift Review of Resident 65's clinical record revealed that the facility's contracted physician's assistant specializing in psychiatry saw them on July 16 and 25, 2024, August 6, 22, and 27, 2024, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 16 of 24 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 01/24/2025 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm September 5, 12, and 19, 2024, October 17 and 29, 2024, November 12, 2024, December 10, 2024, and January 2, and 23, 2025. Further review of Resident 65' clinical record revealed that the facility's physician or physician's assistant saw them on August 23 and 26, 2024, September 10, 12, 25, and 27, 2024, October 17, 2024, November 3 and 24, 2024, December 2, 9, 19, 20, 24, and 29, 2024, and January 2, 5, and 19, 2025. Residents Affected - Some On January 13, 2025, the consultant pharmacist reviewed Resident 65's medications and recommended to evaluate if the PRN Ativan can be discontinued or if a 14 day stop date can be added. The facility's physician and contracted physician's assistant specializing in psychiatry responded other and PRN Ativan has a 90 day stop date due to ongoing anxiety .will continue to evaluate in the future. There was no other documentation available, which indicated Resident 65 had behavior(s) or that they were unable to be seen by a provider to justify and/or necessitate the need for extension of Resident 65's PRN Ativan medication longer than 14 days per regulatory compliance. Review of Resident 65's August through December 2024, and January 2025's, MAR (medication administration record, a form to document medication administration) revealed that the facility administered Ativan 0.5 mg PRN on the following dates: August 31, 2024, at 5:38 PM September 1, 2024, at 10:02 AM September 2, 2024, at 8:30 PM September 11, 2024, at 9:32 AM September 20, 2024, at 9:06 AM September 21, 2024, at 9:00 AM September 22, 2024, at 8:38 AM September 28, 2024, at 9:03 AM September 29, 2024, at 10:19 AM October 7, 2024, at 11:15 AM October 8, 2024, at 9:24 AM October 10, 2024, at 12:50 PM October 13, 2024, at 9:45 AM October 14, 2024, at 9:20 AM October 15, 2024, at 1:39 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 17 of 24 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 01/24/2025 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)

F 0758 October 18, 2024, at 7:24 AM Level of Harm - Minimal harm or potential for actual harm October 19, 2024, at 7:20 AM October 20, 2024, at 10:12 AM Residents Affected - Some October 22, 2024, at 9:02 AM October 23, 2024, at 1:39 AM, 11:40 AM, and 8:03 PM October 28, 2024, at 7:49 AM and 8:31 PM October 30, 2024, at 8:51 PM November 1, 2024, at 12:00 PM November 2, 2024, at 7:43 AM November 3, 2024, at 10:48 AM November 5, 2024, at 8:30 AM November 8, 2024, at 5:00 PM November 10, 2024, at 8:15 AM November 13, 2024, at 8:42 AM November 14, 2024, at 8:14 AM November 15, 2024, at 2:36 PM November 16, 2024, at 9:05 AM November 17, 2024, at 1:54 PM November 20, 2024, at 8:05 AM and 3:57 PM November 21, 2024, at 8:36 AM December 1, 2024, at 8:20 AM December 3, 2024, at 9:13 AM December 7, 2024, at 4:00 PM December 8, 2024, at 3:11 AM December 9, 2024, at 3:20 AM and 3:19 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 18 of 24 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 01/24/2025 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)

F 0758 December 10, 2024, at 8:28 AM Level of Harm - Minimal harm or potential for actual harm December 11, 2024, at 2:51 AM December 13, 2024, at 1:18 PM Residents Affected - Some December 14, 2024, at 7:42 AM December 16, 2024, at 4:00 PM December 19, 2024, at 8:51 AM December 20, 2024, at 5:02 PM December 21, 2024, at 4:21 PM December 24, 2024, at 6:28 PM December 26, 2024, at 4:11 PM December 28, 2024, at 7:20 AM December 29, 2024, at 12:42 AM and 8:46 AM There was no documentation that indicated non-medicinal interventions were attempted prior to administering the PRN Ativan medications. The surveyor reviewed this information during an interview with the Nursing Home Administrator and Director of Nursing on January 23, 2025, at 12:25 PM. 483.45(d)(e)(1)-(2) Drug Regimen is Free from Unnecessary Drugs Previously cited deficiency 2/16/24 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 19 of 24 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 01/24/2025 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and staff interview, it was determined that the facility failed to secure treatments on one of four nursing hallways (North Hall, Resident 56). Findings include: Observations of Resident 56's room on January 21, 2025, at 10:02 AM, January 22, 2025, at 10:19 AM, and January 23, 2025, at 10:52 AM, revealed two open bottles of Dakin's solution (an antiseptic used to treat and prevent infections in wounds), and a bottle of Derma wound cleanser (antiseptic for skin and wounds) on the windowsill. The label on the bottle read to keep out of reach of children, and if swallowed to get medical help, or call poison control. The above findings for Residents 56 and were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on January 23, 2025, at 2:29 PM. The Director of Nursing confirmed the above-mentioned items should not be stored on Resident 56's windowsill. 483.45(g)(h)(1)(2) Label/store Drugs and Biologicals Previously cited deficiency 2/16/24 28 Pa. Code 211.9 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 20 of 24 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 01/24/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen. Findings include: Observation of the facility's main kitchen on January 21, 2025, at 8:58 AM with Employee 1, dietary director, revealed the following: Two large bulk clear plastic containers were observed on a lower shelf of a production table with a white substance in each container. One container was labeled as flour and the other sugar, but there was no date to indicate when the products were placed in the containers or when they needed used by. Several white potholders were observed sitting on top of the convection oven. The potholders were soiled with dried foods and significantly stained. The bottom shelf of the steamer and prep table had dried food debris. The bottom shelf of the steamer and lower shelf of the production table across from the steamer contained dust and dried food debris. The flooring under and behind the steamer and the table beside the steamer contained dried food and debris buildup. The area surrounding a pipe where it enters the floor behind the steamer was caked up with dried food and debris. A two-door cooler behind the serving line contained multiple shelves in the unit with exposed rust colored metal where the protective coating of the shelves had worn off. The exterior of the ceiling vents over the wall of coolers, the vents over the single door food cooler above the serving line, and the vents at the exit door of the kitchen to the resident hallway were covered in dust. The ceiling tile and light covers surrounding the vent over the single door cooler by the serving line were also covered in dust. Another ceiling tile over the single door cooler was significantly brown stained and drooping around a hole where an electrical cord came down through the tile to the single door cooler by the serving line. The plate warming unit contained dried food splatter on the exterior sides of the unit and the lower corner bumpers contained debris and dust. Observation of the food serving temperature log for January 21, 2025, revealed no temperatures were recorded for the items served at the breakfast meal that day as Employee 1 indicated breakfast had already been served to residents. There was no evidence that temperatures were checked for the food served. The temperature log also did not have temperatures recorded for breakfast January 20, 2025; the day prior. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 21 of 24 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 01/24/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm A follow up observation in the main kitchen on January 23, 2025, at 11:45 AM revealed four potholders sitting on top of the convection oven. The potholders were blackened and covered in dried food. The above information was reviewed with the Nursing Home Administrator and Director of Nursing on January 23, 2025, at 2:30 PM. Residents Affected - Many 483.60(i)(2) Store, prepare, food safe and sanitary Previously cited 2/16/24 28 Pa. Code 201.14 (a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 22 of 24 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 01/24/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and staff interview, it was determined that the facility failed to prevent the potential spread of infection during medication administration pass for two of five residents observed (Residents 10 and 60), during a dressing change for one of one resident observed for a dressing change (Resident 50), and failed to adhere to enhanced barrier precautions for one of one resident observed during observation of a dressing change (Resident 50). Residents Affected - Some Findings include: Observation of Employee 8 (Licensed Practical Nurse, LPN) during a medication administration pass on January 23, 2025, at 8:35 AM revealed she prepared the following medications for Resident 10, Famotidine (a medication used to treat ulcers of reflux disease) 20 milligrams (mg) two capsules; Mucinex (a medication used to treat cough caused by the common cold) 600 mg one tablet; One daily with minerals (a multi vitamin) one tablet; Vitamin D3 (used to supplement vitamin D in the body) 1000 units, one capsule; Colace (a medication used to treat or prevent constipation) 100 mg one capsule; and Fexofenadine (a medication used to treat seasonal allergies) 180 mg one tablet, by taking them out of the bottle with her ungloved (bare) hand and placing them into the medication cup. Observation also revealed she punched out of a punch card the medication Clopidogrel (a medication used to prevent blood clots) that landed on top of her medication cart. She then picked up the pill with her ungloved hand and placed it into the medication cup. She entered Resident 10's room and administered the medications to her. Observation of Employee 8, LPN, during a medication administration pass on January 23, 2025, at 8:25 AM revealed she prepared the following medication for Resident 60, Famotidine 20 mg one capsule, by taking it from the bottle with her ungloved hand and placing it into the medication cup. She then entered Resident 60's room and administered the medication to her. Concurrent interview with Employee 8, confirmed the above noted findings. The Nursing Home Administrator and Director of Nursing were made aware of the concerns with medication administration pass on January 23, 2025, at 2:55 PM. Observation of Employee 9 , Registered Nurse, infection preventionist, and wound nurse, on January 24, 2025, at 10:30 AM during a dressing change of Resident 50's left lateral heel pressure ulcer, revealed she entered the room with her supplies and place them on Resident 50's overbed table. She did not clean or prepare the overbed table first, failing to establish a clean field for her supplies. She then sanitized her hands and donned gloves. She raised Resident 50's bed, removed her gloves, sanitized her hands, and put on a new pair of gloves. Without changing her gloves, Employee 9 then completed the following actions: took off Resident 50's non-skid sock, removed the old dressing, (Employee 9 should have donned new gloves) cleansed the area with normal saline solution and gauze, applied betadine to the area, covered it with a new dressing, reapplied residents' non-skid socks, discarded the old dressing, cleaned up her supplies, removed gloves, and washed her hands. Observation of the door to Resident 50's room revealed no sign indicating he was on enhanced barrier precautions (EBPs, precautions used to prevent the spread of multi-drug resistant organisms). Concurrent interview with Employee 9 revealed that EBPs should have been used when doing the dressing change to include a gown in addition to the gloves she wore. She also indicated that she should have set up a clean surface for her dressing supplies and changed her gloves after removing the old (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 23 of 24 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 01/24/2025 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)

F 0880 dressing from Resident 50's left heel. Level of Harm - Minimal harm or potential for actual harm The Nursing Home Administrator and the Director of Nursing were made aware of concerns with Resident 50's dressing change concerns and concerns with enhanced barrier precautions on January 24, 2025, at 11:10 AM. Residents Affected - Some 28 Pa. Code 201.18 (d) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395396 If continuation sheet Page 24 of 24