Health inspection·September 25, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide services to maintain a clean and homelike environment for four out of five nursing units (Units Medbridge Hall, A Hall, B Hall, and D Hall), including experiences reported by two out of three residents interviewed (Residents 1 and 2). Findings include:A review of resident council meeting minutes dated August 4, 2025, revealed residents in attendance expressed concerns regarding the housekeeping services. Residents reported that only garbage is emptied, and floors are occasionally mopped. Additional concerns included housekeepers using dirty water to mop floors, particularly in hallways and dining areas; lack of top dusting; dusty surfaces; spider webs; over-bed tables not being cleaned; and bathroom floors uncleaned. Observations on September 25, 2025, at 8:26 AM revealed a black mat with multiple pieces of white debris, a wet paper towel, and black-gray discolorations in front of the ice machine in the Medbridge Nursing Unit dining area.Observations on September 25, 2025, at 8:44 AM revealed a clump of hair measuring 2 inches by 1 inch and multiple pieces of dirt and debris in the Nursing A Hall.Observations on September 25, 2025, at 8:51 AM revealed missing and stained tiles, saturated paper, and hair in the B Hall shower room drain. A resident bathtub in the B Hall shower room was also observed with several pieces of hair and debris inside the tub. The shower room floor had multiple areas with discolorations, a discarded plastic glove, stains, and pieces of debris.Observations on September 25, 2025, at 8:55 AM revealed dirt, debris, and stains on the floor around the A Hall nursing station. The running board adjacent to the Nursing A Hall nursing station was observed with a brown-red substance stain and buildup.A clinical record review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses that included schizophrenia (a chronic mental health condition characterized by a combination of symptoms, such as flat affect, hallucinations, and/or impairments with cognitive functioning, that significantly impact a person's thoughts, emotions, and behaviors).A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 3, 2025, revealed that Resident 1 was moderately cognitively impaired with a BIMS score of 10 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderate cognitive impairment).During an interview on September 25, 2025, at 8:57 AM, Resident 1 stated that his room is never cleaned. He explained that he saw staff cleaning today because the surveyors were here. An observation of Resident 1's room revealed the resident's floor with a substance splattered near his bed measuring 5 inches by 10 inches, small white pieces of paper, dirt, and debris.Observations on September 25, 2025, at 8:58 AM revealed the Resident B Hall hallway with dirt, debris, and a substance buildup on the edges of the floor near the baseboard. The dirt and Page 1 of 3 395397 395397 09/25/2025 Edenbrook on Second Ave 200 Second Avenue Kingston, PA 18704

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some substance buildup extended several feet along the B Hall walls on both sides.Observation on September 25, 2025, at 9:35 AM revealed Resident D Hall's shower room with a floor with dirt, debris, and discolorations; a bathtub with brown substance stains; a shower chair with brown substance stains on the seat opening; and a drain with clumps of hair.Observations on September 25, 2025, at 9:45 AM revealed the Resident B Hall lounge with two overlapping trays. Both trays had multiple substance stains on the base of the trays. A green rocking chair was observed with a red substance buildup near the armrest measuring 2 inches by 4 inches. The floor of the B Hall lounge was observed with pink and red stains.A clinical record review revealed Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).A review of a quarterly Minimum Data Set assessment (MDS) dated [DATE], revealed that Resident 2 was cognitively intact with a BIMS score of 15; a score of 13-15 indicates cognition is intact.During an interview on September 25, 2025, at 9:55 AM, Resident 2 explained the facility staff do not clean every day, and it has been this way for a while. Resident 2 pointed out a buildup of dirt, dust, discolorations, and debris that ran along the wall of her room near her closet.An observation on September 25, 2025, at 10:04 AM revealed the Medbridge Hall hallway adjacent to the nursing station with brown liquid stains on the wall and dirt, debris, and dust on the floor near the floorboards.An observation on September 25, 2025, at 10:07 AM revealed resident room [ROOM NUMBER]'s window side wall with brown-gray liquid stains and dirt, debris, cobwebs, and a leaf near the tall armoire. The resident bathroom was observed with brown substance stains on the floor and a brown substance smear near the shower drain.An observation on September 25, 2025, at 10:10 AM revealed the Medbridge Hall hallway outside of resident room [ROOM NUMBER] with paper, plastic pieces, and red stains.An observation on September 25, 2025, at 10:16 AM revealed the Medbridge Hall shower room with a clump of brown substance near the shower drain and brown substance smears on the floor. There was dirt, debris, stains, and dust in multiple areas of the shower room floor.During an interview on September 25, 2025, at 10:45 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to provide services to maintain a clean and homelike environment for all residents living at the facility. 28 Pa. Code 201.18 (e)(1) (2.1) Management.28 Pa. Code 201.29 (a) Resident rights.28 Pa. Code 211.12 (d)(3) Nursing services. 395397 Page 2 of 3 395397 09/25/2025 Edenbrook on Second Ave 200 Second Avenue Kingston, PA 18704

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interviews, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and three of five resident pantry areas (Nursing Units Medbridge Hall, A Hall, and B Hall). Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean, and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness, according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). Observations on September 25, 2025, at 8:28 AM revealed the kitchen floor with dirt, discolorations, dust, and food pieces along the kitchen floor perimeter. Observations on September 25, 2025, at 8:36 revealed the A Hall pantry with an opened, undated chocolate instant pudding mix; cabinets with dust and discolorations; a refrigerator with substance stains and discolorations; and a microwave with used brown napkins and substance stains inside and around the exterior of the appliance. Observations on September 25, 2025, at 8:43 AM revealed the B Hall pantry with an opened plastic bag containing white crackers, a microwave with food substance stains and pieces of food, and a refrigerator with a soiled brown paper towel. Observations of September 25, 2025, at 10:12 AM revealed the Medbridge Hall pantry with an undated plastic bowl containing a tan food in the refrigerator. The refrigerator had brown-red substance stains along the bottom shelf and an undated frozen liquid drink in the freezer. The microwave was observed with food pieces and a substance stain on the interior of the appliance. An interview with the nursing home administrator on September 25, 2025, at 10:45 AM confirmed the food and nutrition services department and resident pantry areas were to be maintained in a sanitary manner and confirmed food items were to be dated to ensure quality and food safety to prevent opportunities for foodborne illness. 28 Pa Code 211.6(f) Dietary services. 28 Pa Code 210.18 (e) (2.1) Management. 395397 Page 3 of 3