Inspection·March 4, 2025

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 of select facility policies, and staff interview, it was determined that the facility failed to provide the highest practical care related to bowel management for one of four residents reviewed (Resident 1) Residents Affected - Some Findings include: The current facility policy entitled Standing Orders for Skilled Nursing Facility, revealed the following orders are initiated from standing orders. The bowel and gastrointestinal (organs that help with digestion) protocol includes nursing staff will administer residents Milk of Magnesia (MOM) 30 milliliters (mL) by mouth on the day shift of day three without a bowel movement. Nursing staff are to administer a Dulcolax Suppository 10 milligram (mg) on the evening shift of day three if the Milk of Magnesia is ineffective. Nursing staff are to administer a Fleet's enema as needed on day four without a bowel movement if no results from the suppository. Nursing staff can administer 15 to 30 mL every two hours for as needed gastrointestinal distress. Clinical record review for Resident 1 revealed the facility initiated a plan of care to address Resident 1's constipation on July 9, 2024. Interventions included that the resident would follow the bowel protocol if constipation occurs. Clinical record review for Resident 1 revealed the following physician orders to promote bowel movements: Milk of Magnesia 400 mg per 5 ml (milliliters) (MOM, laxative that pulls water into bowel to soften bowel contents) Give 30 ml by mouth as needed (PRN) and administer if no bowel movement by the third day (day shift). Dulcolax suppository (Bisacodyl, a laxative medication used to relieve constipation) insert one suppository rectally as needed for constipation for no bowel movement after administration of MOM (evening shift). Fleet's Enema 7-19 gm (grams) per 118 ml (Sodium Phosphates, liquid medication inserted into the rectum to treat constipation). Insert 1 applicatorful rectally for no bowel movement by the fourth day (day shift) if no results from administration of suppository or MOM. Review of bowel elimination records for Resident 1 revealed that staff documented no bowel movements for January 28, 29, 30 and, 31, 2025. There was no documentation of Resident 1's bowels from February 1 to 4, 2025. Further review of Resident 1's bowel elimination record revealed that staff documented no bowel movements for February 5, 6, 7, 8, 9,10, 11, 12, 13, 14, 15, 16, 17, and 18, 2025. (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 4 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 03/04/2025 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)