Edenbrook On Second Ave

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 REDACTED], 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 REDACTED], 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.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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