Health inspection·February 19, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy, documentation provided by the facility, and staff and resident family interviews, it was determined the facility failed to ensure residents have the right to personal privacy for one resident out of eight sampled (Resident 1). Residents Affected - Few Findings include: A review of facility policy titled Photographing, Video and Audio Recording, and Other Imaging of Residents, Visitors, and Associates, dated April 1, 2022, revealed it is the facility's policy to take reasonable steps to protect residents, visitors, and associates from unauthorized photography, video or audio recordings, or other images. The policy indicates photography and audio recording of residents within the facility by associates for personal use is prohibited. A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that include down syndrome (a genetic condition that causes physical and intellectual disabilities) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 12, 2024, Section C1000. Cognitive Skills for Daily Decision Making revealed Resident 1 is severely impaired in her ability to make decisions regarding tasks of daily life. Further review of the MDS revealed a Brief Interview for Mental Status (BIMS- a tool used to identify cognitive impairment) was not completed because Resident 1 is rarely or never understood. A review of a facility investigative report indicated a witness statement dated February 10, 2025, revealed Employee 1, Nurse Aide (NA), stated, I sure did take a picture of Resident 1 and showed it to her family member. During an interview on February 19, 2025, at 8:25 AM, Resident 1 was not able to answer questions or communicate her thoughts or ideas when greeted. During a telephone interview on February 19, 2025, at 9:32 AM, Resident 1's family member expressed concerns that a facility employee took a photograph of Resident 1 on her personal mobile device. The family member indicated that she is Resident 1's Power of Attorney and confirmed that no consent had been given for the photograph, and the family member requested that any images of Resident 1 be deleted immediately. Attempts to contact Employee 1 for further investigation were unsuccessful, and the provided phone (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 2 Event ID: 395397 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 02/19/2025 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)