Health inspection·November 26, 2024

F 0558 Reasonably accommodate the needs and preferences of each resident. 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, observation, and staff and resident interviews, it was determined the facility failed to reasonably accommodate a request and need for more frequent bed linen changes for one resident out of eight residents sampled (Resident 2). Residents Affected - Few Findings incudes: Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses to include morbid obesity (complex chronic disease in which a person has a body mass index of 40 or higher) and lymphedema (chronic condition that causes tissue swelling usually in the arms or legs in which accumulated fluid could break the skin resulting in leakage). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 31, 2024, revealed the resident had a BIMS (brief interview for mental status- tool to screen and identify the cognitive condition of long-term care residents) score of 15 (a score of 13-15 indicates cognitively intact), required the assistance of one staff member for bed mobility, and the assistance of two staff members for transfers. During an interview conducted on November 26, 2024, at 11:45 AM Resident 2 stated that he utilizes a bariatric bed (a specialized bed to accommodate overweight or obese patients). Resident 2 stated the sheets frequently need to be changed every shift due to excessive leakage from his legs due his diagnosis of lymphedema. Resident 2 revealed there are times the staff is unable to change the bed because sheets are unavailable. Observation at this time revealed that Resident 2 was lying on visibly soiled sheets. Interview with Employee 1 (laundry aide) on November 26th, 2024, at 12:50 PM revealed the facility frequently did not have enough sheets for Resident 2's bariatric bed to be changed each shift due to the sheets tearing or finding the sheets cut with scissors by other staff to fit the bariatric bed. Interview with the nursing home administrator and director of nursing on November 26, 2024, at approximately at 3:00 PM failed to provide documented evidence that Resident 2's bed linens were being changed frequently enough to ensure a reasonable accommodation of the resident's individual needs. 28 Pa Code 204.13 Linen Page 1 of 4 395397 395397 11/26/2024 Edenbrook on Second Ave 200 Second Avenue Kingston, PA 18704

F 0558 28 Pa Code 201.18 (e)(2.1) Management Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services Residents Affected - Few 395397 Page 2 of 4 395397 11/26/2024 Edenbrook on Second Ave 200 Second Avenue Kingston, PA 18704

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on clinical record and facility policy review and staff interview, it was determined the facility failed to ensure that in preparation for a room change each resident/resident representative received written notice, including the reason for the change before the resident's room was changed for two of 15 room changes completed by the facility from October 30, 2024, through November 4, 2024 (Resident 1 and Resident 2). Findings include: Federal regulatory guidance under §483.10(e)(6) notes that moving to a new room or changing roommates is challenging for residents. A resident's preferences should be taken into account when considering such changes. When a resident is being moved at the request of facility staff, the resident, family, and/or resident representative must receive an explanation in writing of why the move is required. The resident should be provided the opportunity to see the new location, meet the new roommate, and ask questions about the move. A review of the facility Room Change/Roommate Assignment Policy, last reviewed July 2024, indicated that changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. The policy guideline indicated the following: 1) The facility reserves the right to discuss room changes or roommate assignments when the facility deems it necessary or when the resident requests the change. 2) Prior to changing a room or roommate assignment all parties involved in the change/environment (e.g., residents or their representatives will be given advance notice of such change. 3) The notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. 4) When making a change in room or roommate assignment, the resident's needs and preferences will be considered and to the extent practical, will be accommodated. However, the facility will also review the room management policy. 5) Room changes or roommate assignments will not be based on racial or other forms of discrimination. 395397 Page 3 of 4 395397 11/26/2024 Edenbrook on Second Ave 200 Second Avenue Kingston, PA 18704

F 0559 6) Level of Harm - Minimal harm or potential for actual harm Information regarding transfers will be documented in the resident's medical record. 7) Residents Affected - Few Inquiries concerning changes in room or roommate assignment should be referred to the Administrator, Director of Nursing Services, or Social Services. The facility policy noted that the provision of a written explanation of why the move is required to the resident and/or representative may be oral or in writing, or both despite the federal regulatory guidance to receive an explanation in writing of why the move is required. A review of Resident 1's clinical record revealed a Room/Roommate Change Advance Notification Form dated November 4, 2024, indicated the resident was notified on November 4, 2024, that the resident's room would be changed on November 4, 2024, for the reason of room availability. There was no documented evidence the facility provided the form to the resident and/or the resident's representative. A review of Resident 2's clinical record revealed a Room/Roommate Change Advance Notification Form dated October 30, 2024, indicated the resident was notified on October 30, 2024, that the resident's room would be changed on October 30, 2024, because the resident is a short-term resident and will be moved to the short-term side of the building. During an interview with Resident 2, a cognitively intact resident, on November 26, 2024, at approximately 11:45 AM the resident confirmed that he was transferred from his room to another room on October 30,2024, because the resident was deemed as a short-term admission. During this interview the resident stated he did not receive any written notification of the room change. There was no documented evidence the facility provided written notice, with an explanation for the reason for the room change to the resident and/or the resident's representative. A review of documentation provided by the facility revealed the facility initiated resident room changes on 15 occasions between October 30, 2024, and November 4, 2024. During an interview with the nursing home administrator (NHA) on November 26, 2024, at approximately 2:30 PM the NHA failed to provide documented evidence the facility provided any written explanation of the reasons for these moves to the residents and/or their representatives. 28 Pa Code 201.29 (a) Resident Rights 395397 Page 4 of 4