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 Page 1 of 2 395397 395397 02/19/2025 Edenbrook on Second Ave 200 Second Avenue Kingston, PA 18704

F 0583 number was no longer in service. Level of Harm - Minimal harm or potential for actual harm During an interview on February 19, 2025, at approximately 11:00 AM, the Director of Nursing (DON) confirmed that Employee 1, NA, admitted to taking a photograph of Resident 1. The DON explained that Employee 1 was an agency employee and was subsequently placed on the do-not-return list for failure to comply with facility policies. Residents Affected - Few The DON was not able to provide documented evidence that Resident 1 or Resident 1's representative authorized the photographing of Resident 1. The DON and Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure residents at the facility have a right to personal privacy. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa. Code 201.29 (a) Resident rights. 28 Pa. Code 211.12 (c) Nursing services. 395397 Page 2 of 2