Health inspection·January 10, 2025

F 0560 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated the room change negatively affected his sleep, and he often goes to the dining room to sleep due to discomfort in his new room. An interview with the Nursing Home Administrator on January 10, 2025, at approximately 2:40 PM confirmed the facility failed to afford Resident 1 the right to refuse the room change. The facility failed to honor Resident 1's right to refuse the room change and to ensure the move was not made solely for staff convenience. 28 Pa. Code 201.29 (a) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395397 If continuation sheet Page 2 of 4 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 395397 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook on Second Ave 200 Second Avenue Kingston, PA 18704 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility investigative reports, clinical records, and staff interview, it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice for one of 8 sampled residents (Resident 1). Findings include: According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records. According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.145. (a) The licensed practical nurse (LPN) is prepared to function as a member of a health-care team by exercising sound nursing judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure) and type 2 diabetes (disease that occurs when the body doesn't produce enough insulin or doesn't use it properly, resulting in high blood sugar levels). A review of a facility investigative report dated December 24, 2024 at 1:11 AM revealed the resident was heard yelling from the shower room while the staff were helping other residents. The shower chair had collapsed as the resident sat down. Staff responded to the shower room and the resident had already gotten himself back into his wheelchair. The resident was noted to have scratches on his sacrum (area at the base of the spine) and legs. At that time, it was indicated the resident was not taken to the hospital. Further review of the investigative report revealed a note dated December 24, 2024, indicating at 11:00 PM on December 23, 2024, staff were made aware that the resident had a fall in the shower room. Scratches were noted to his sacrum and legs which were cleaned, and a dressing was applied. The resident then informed staff at 2:15 AM that his head was hurting, and he felt nauseous and wanted to go to the hospital. The ambulance was called, and the resident was transferred to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395397 If continuation sheet Page 3 of 4 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 395397 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook on Second Ave 200 Second Avenue Kingston, PA 18704 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 0842 Level of Harm - Minimal harm or potential for actual harm A review of the resident's clinical record revealed the facility failed to document the resident's fall and transfer to the hospital. The clinical record failed to identify what time the fall occurred occurred, any assessments that were performed after the fall, and if the resident had injuries, or what time the resident was transferred out to the hospital. Further there was no documentation the resident's physician was notified after the fall occurred. Residents Affected - Few An interview with the Nursing Home Administrator and Director of Nursing on January 10, 2025, at approximately 2:40 PM confirmed the facility's nursing staff failed to document consistently and accurately in the residents' clinical records. As a result, the residents' clinical records were inaccurate and incomplete. 28 Pa. Code 211.5 (f)(iii)(viii)(ix) Medical records. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395397 If continuation sheet Page 4 of 4