Health inspection·November 17, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy and investigative reports resident and staff interview, it was determined that the facility failed to ensure that two residents were free from physical abuse out of 30 sampled residents (Resident 103 and Resident 32). Findings including Review of a facility policy entitled Abuse Policy - PA with a policy review date of August 14, 2023, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's abuse policy indicated that it was the policy of the facility that each resident would be free from abuse. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility and that abuse or harm of any type would not be tolerated, and residents and staff would be monitored for protection. The facility would strive to educate staff and other applicable individuals in techniques to protect all parties. Further review of the abuse policy indicated that the facility's population presented as a factor that could result in maltreatment of residents such as residents with cognitive deficits, sensory deficits, aggressive behaviors, residents who have behaviors such as entering other residents' rooms, wandering behaviors, socially inappropriate behaviors, verbal outbursts, and residents with communication deficits. Additionally, the facility would ensure a comprehensive dementia management program to prevent resident abuse, if applicable. A review of Resident 140 was admitted to the facility on [DATE], with diagnoses that included late on-set Alzheimer's dementia and dysphagia (difficulty swallowing) post cerebral vascular accident (stroke). Review of Resident 140's quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE], revealed that the resident had severe cognitive impairment and ambulated without an assistive devise. According to the assessment the resident displayed physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurring one to three days, verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occurred one to three days and wandering occurred four to six days during the assessment observation period. A review of Resident 140's care plan dated June 6, 2023, revealed that the resident had the potential to be physically aggressive related to anger and dementia and a goal for the resident does not harm self or others, the resident would demonstrate effective coping skills, and the resident would seek out staff/caregiver when agitation occurs. Planned interventions were to analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, administer medications as ordered and monitor/document the effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits, and assess when the resident becomes agitated: intervene before agitation escalates, guide away (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 2 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some from source of distress, engage calmly in conversation, and if the response is aggressive, staff to walk calmly away, and approach later. The resident's care was revised on August 1, 2023, and September 18, 2023, to include the resident's behavior problems related to Alzheimer's such as places self on floor, reaching over nurses' station, attempting to throw computer/laptops, throwing water cups. Noted interventions included to intervene as necessary to protect the rights and safety of others, encourage activity participation, and monitor behaviors related to use of psychotropic medication, Risperdal. A nursing progress note completed by Employee 4, an agency registered nurse (RN) dated with an effective date of September 2, 2023, at 4:50 PM, and a create date of September 3, 2023, at 5:31 AM, revealed that the RN Supervisor was notified that the resident's roommate returned from the hospital. Per licensed practical nurse (LPN) and nurse aide (NA), the resident immediately became agitated and abusive towards roommate stating why the fuck are you in here? Get out f*ck out of here. Proceeding to try to push roommate and the NA and LPN had to intervene to protect patient's roommate. Resident removed from room at this time to avoid further confrontation. A review of an order administration note completed by Employee 5, a LPN, dated September 2, 2023, at 5:41 PM, revealed that ABH gel (0.5 mg Ativan /25 mg Benadryl/0.5 mg/ Haldol Gel) [is a compound that is made up of lorazepam, diphenhydramine, and haloperidol that is prescribed for individuals in hospice and palliative care settings for the treatment of nausea and vomiting and terminal delirium/agitation] 0.5-25-0.5 mg/ 1 ml cream was applied to a hairless area topically every 6 hours as needed for agitation for 90-days due to Resident 140 becoming agitated, hitting staff, attempting to opening med-cart. Med cart then locked and attempted to redirect and was ineffective. Resident 140 was throwing things off the top of the med-cart and the resident was cursing and calling staff names and continued wandering in hallway. PRN (as needed) medication administered on resident's back. The resident was under close supervision due to behaviors and for safety reasons. A review of a facility behavior problem incident report completed by Employee 9, a registered nurse (RN) dated September 2, 2023, at 10:30 PM, revealed that Resident 140 was involved in a resident-to-resident altercation. Resident 140 was heard cursing at Resident 32, who had been seated in chair in the hallway quietly. While staff were coming up the hall to break up the altercation, staff witnessed Resident 140 slapping Resident 32 on both arms forcefully several times. Three staff members broke up the altercation and redirected resident {Resident 140} to her room while she preceded to scream and curse at staff. The hallways were cleared of any residents to attempt to prevent further issues at this time. Resident 140 was ambulating around the hallways at this time. RN supervisor made aware. A review of Resident 103's nurses progress note that was completed by Employee 15, an agency RN, dated September 4, 2023, at 12:03 AM, revealed that the resident was in an altercation with Resident 140 this evening. Resident 103 went towards Resident 140 and with a closed fist, hit her {Resident 103) in the upper back. No injuries noted, no bruising at this time, no open areas. Vitals were obtained, no pain reported, and the attending physician and RP (responsible party) were notified. Further review of Resident 140's clinical record revealed that on September 4, 2023, at 11:25 AM, that the resident transferred to the emergency department for an evaluation due to increase of behaviors and resident to resident altercations. She returned to the facility from the emergency department on September 4, 2023, at 3:01 PM, and was placed on 1:1 for increased supervision and safety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 3 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of a facility behavior problem incident report completed by Employee 9, a registered nurse (RN) dated October 6, 2023, at 5:05 PM, revealed that as Resident 32 was rushing to sit down in the dining room chair before Resident 140 attempted to sit in the chair, Resident 140 became angry, made a fist, swung laterally, and hit Resident 32 in the chest and then kept on walking. Resident 140's assigned 1:1 staff member was at arm's length ambulating with her when Resident 140's behavior was swift and unpredictable as she kept on walking after the incident. Post incident assessment revealed that Resident 32 did not have apparent injuries at that time. The facility failed to protect residents from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors {Resident 140} to prevent repeated resident-to-resident altercations. The facility failed to implement measures to limit other residents' access to Resident 140's personal space and to maintain a safe distance between Resident 140 and other residents to decrease triggers that may cause Resident 140 to strike out and physically abuse other residents. During an interview with the Nursing Home Administrator (NHA) on November 16, 2023, at 1:55 PM, confirmed that the facility failed to monitor residents with known verbal and physical aggressive behaviors and failed to provide an environment that protects cognitively impaired residents free from physical abuse. A review of Resident 21's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included unspecified dementia, cognitive communication deficit [is a difficulty with communication that is caused by a cognitive impairment], and chronic kidney disease [is a condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic and disease progression occurs slowly over time]. A review of Resident 21's care plan dated December 2, 2022, identified that the resident had potential to be verbally and physically aggressive towards staff and other residents related to diagnosis of dementia with planned interventions included analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, intervene before agitation escalates and guide away from source of distress, and to offer activities as diversion with increased behaviors such as coloring, card games, or crossword puzzles. A review of the resident's quarterly MDS assessment dated [DATE], revealed that the resident had severe cognitive impairment and frequently exhibited the presence of physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred one to three days, and verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occurred four to six days and wandering. A facility behavior problem incident report completed by Employee 18, a LPN, dated October 7, 2023, at 10:00 PM, revealed that Resident 121 came to the nurse's station and said, my roommate {Resident 21} said she was going to hit me, and she did. Resident 21 came to the door of their room and as Resident 32 passed by Resident 21 open-handedly slapped her {Resident 32} in the arm. Neither Resident 121 nor Resident 32 had injuries and were re-directed to a safe area by staff. Resident 21's attending physician was notified with new orders to the hospital for an evaluation and treatment. A review of a witness statement completed by Resident 121 (BIMs score of 13, cognitively intact), dated October 16, 2023, no time indicated, noted I was walking out of the room when she {Resident 21} (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 4 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0600 hit me in anger in my shoulder that has arthritis, and walked the hall. Level of Harm - Minimal harm or potential for actual harm A witness statement completed by Employee 17 dated October 16, 2023, no time indicated, noted that the resident {Resident 21} was standing in her doorway while police officers were talking to her. She {Resident 21} threatened to kick one of the officers in the scrotum. When she did attempt to kick him with her right foot, he took her by the leg and gently assisted her down to the floor. The two officers the guided her onto the litter. The resident offered no complaints of pain. Residents Affected - Some A behavior problem incident report completed by Employee 19, a LPN, dated October 21, 2023, at 10:07 AM, revealed that she heard yelling in the dining room, noticed that resident {Resident 21} standing next to another resident {Resident 95} and yelling at her. Resident 95 was sitting in her assigned lunch seat. The resident {Resident 95} stated that she {Resident 21} hit her and that she was okay. An RN assessment noted that Resident 21 was the aggressor and was observed slapping another resident {Resident 95} on her arm. The resident did not remember and refused to speak to the nurse. The attending physician was notified and ordered to continue with Rexulti [a medication used in conjunction with antidepressant medicines to treat major depressive disorder in adults and also used treat agitation that may happen with dementia due to Alzheimer's disease], and to discontinue Ativan gel due to the resident refusing to allow placement. The facility failed to protect residents from physical abuse and failed to effectively monitor and supervise a resident with known episodes of aggressive behaviors {Resident 21} to prevent repeated resident-to-resident altercations. Interview with the NHA on November 16, 2023, at 2:00 PM, confirmed that the facility failed to monitor and supervise a resident with known verbal and physical aggressive behaviors and failed to provide an environment that protects residents from physical abuse. 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a)(c)(d) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 5 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on a review of employee personnel files and staff interviews, it was determined that the facility failed to implement abuse prohibition procedures to fully screen three out of five employees to ensure that they were eligible for employment in a long term care nursing facility. Residents Affected - Some Findings include: In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police background check within 30 days of hire on all prospective employees. If the prospective employee does not have continuous residency in Pennsylvania for two years prior to employment then the facility is required to obtain a Federal Bureau of Investigation (FBI) check within 90 days. Review of employee files revealed that Employee 1 (dietary Aide) was hired August 29, 2023. A Pennsylvania State Police background check was submitted August 24, 2023, with the request still pending for control at the time of the survey ending November 17, 2023. There was no indication the facility obtained the results of the Pennsylvania State Police background check to ensure the employee was eligible for employment in a long term care nursing facility. Employee 2 (Nurse Aide) was hired August 18, 2023, a Pennsylvania State Police background check was not requested until surveyor inquiry during the survey on November 16, 2023. There was no indication that the facility obtained the Pennsylvania State Police background checks within 30 days of hire. Employee 2 also had no employment application in her file and there was no indication that the facility attempted to contact a previous employer. A review of the personnel file revealed that Employee 3 (RN Supervisor) was hired September 15, 2023. Upon review during the survey ending November 17, 2023, there was no employment application in her file and there was no indication that the facility contacted a previous employer. Interview with the Administer in Training (AIT) on November 17, 2023 at 11:15 a.m. confirmed the above findings and the absence of the documentation to show that the facility fully screened the above employees for employment. 28 Pa. Code 201.29(a)(c) Resident rights 28 Pa. Code 201.19 (1) Personnel records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 6 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a written notice of facility-initiated transfer to the hospital was provided to the resident and resident's representative for five residents out of 17 residents sampled (Residents 23, 35, 53, 110, and 113). Findings include: A review of Resident 23's clinical record revealed that the resident was transferred to the hospital on December 31, 2022, and returned to the facility on January 2, 2023. The resident was again transferred to the hospital on July 24, 2023, and returned to the facility on August 2, 2023. A review of Resident 35's clinical record revealed that the resident was transferred to the hospital on January 6, 2023 and returned to the facility on January 7, 2023. A review of Resident 53's clinical record revealed that the resident was transferred to the hospital on July 30, 2023, and returned to the facility on August 1, 2023. A review of Resident 110's clinical record revealed that the resident was transferred to the hospital on July 31, 2023, and returned to the facility on August 3, 2023, transferred to the hospital on August 22, 2023, and returned to the facility on August 23, 2023, and again was transferred to the hospital on October 16, 2023, and returned to the facility on October 18, 2023. A review of Resident 113's clinical record revealed that the resident was transferred to the hospital on May 31, 2023, and returned to the facility on June 7, 2023. There was no evidence of the written notice provided to the residents and their representatives of the facility-initiated transfers to the hospital for the transfers noted above. Interview with the Administrator on November 16, 2023, at approximately 10:30 a.m. confirmed that there was no evidence that written notifications of transfer were provided to the residents and their representatives. 28 Pa. Code 201.29 (c.3)(2)Resident Rights. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 7 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on clinical record review and staff interview, it was determined that the facility failed to provide evidence of written information of the facility's bed hold policy provided to the resident and their representative upon transfer to the hospital for five residents out of 17 residents sampled (Residents 23, 35, 53, 110, and 113). Findings include: A review of Resident 23's clinical record revealed that the resident was transferred to the hospital on December 31, 2022 and returned to the facility on January 2, 2023. The resident was again transferred to the hospital on July 24, 2023, and returned to the facility on August 2, 2023. A review of Resident 35's clinical record revealed that the resident was transferred to the hospital on January 6, 2023 and returned to the facility on January 7, 2023. A review of Resident 53's clinical record revealed that the resident was transferred to the hospital on July 30, 2023 and returned to the facility on August 1, 2023. A review of Resident 110's clinical record revealed that the resident was transferred to the hospital on July 31, 2023 and returned to the facility on August 3, 2023, transferred to the hospital on August 22, 2023 and returned to the facility on August 23, 2023, and again was transferred to the hospital on October 16, 2023 and returned to the facility on October 18, 2023. A review of Resident 113's clinical record revealed that the resident was transferred to the hospital on May 31, 2023, and returned to the facility on June 7, 2023. The facility was unable to provide documented evidence, by the end of the survey on November 17, 2023, that the facility had provided the residents and the residents' representatives written information, at the time of transfer, of the specifics of the facility's bed hold policies, including notice of the duration of the bed-hold policy and the cost of holding a bed. Interview with the Administrator on November 16, 2023, at approximately 10:30 a.m. confirmed that there was no evidence that written notifications at the time of transfer were provided to the residents and their representatives of the specifics of the facility's bed hold policies, including notice of the duration of the bed-hold policy and the cost of holding a bed. 28 Pa Code 201.18 (e)(1) Management 28 Pa Code 201.29 (c.3)(1) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 8 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, the facility Bed Hold Notices provided to residents upon transfer from the facility and interview with facility staff it was determined that the facility failed to demonstrate the implementation of specifically delineated procedures for Medicare payor source bed holds and the provision of notices of the facility's bed hold policy to ensure that a resident transferred from the facility with the expectation of returning to the facility was permitted to return or met the specific requirements for a facility initiated discharge for one out three discharged residents reviewed (Residents 148). Findings included: Review of the facility Notification of Bed Hold/Transfer indicated that if a resident who is Medicaid eligible and actively covered under the Medicaid program requires hospitalization, the facility agrees to hold the residents bed for up to 15 days as required by federal regulation. Review of Resident 148's clinical record indicated the resident was admitted to the facility on [DATE], and was Medicaid payor source. The resident was transferred to the hospital on September 18, 2023, and the bed hold policy in effect. The resident returned to the facility on September 20, 2023. Nurses note on October 9, 2023 at 3:41 p.m. indicated that Acute Care Transfer completed with the following items sent with the resident, Transfer/ Discharge Record, and a copy of Bed Hold Policy with Supplemental Documentation attached. A review of the clinical record revealed that Resident 148 was transferred to an acute care facility on October 9, 2023, as the facility was unable to flush her feeding tube and a stitch became dislodged. An order was given to send the resident to the ER for evaluation and treatment. The facility discharged the resident at the time of her transfer to the hospital and there was no bed hold. Interview with the Administrator on November 16, 2023 at 10:45 a.m. the NHA confirmed that the facility discharged the resident on October 9, 2023 and did not hold a bed for Resident 148. 28 Pa. Code 201.29(a) Resident Rights. 28 Pa. Code 201.18 (e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 9 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0641 Ensure each resident receives an accurate assessment. 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 and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 8 sampled (Resident 106). Residents Affected - Few Findings include: According to the RAI User's Manual, Section A 1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change or annual assessment. admission MDS' Assessments of Resident 106 dated August 3, 2023, revealed Section A 1500 was coded as 0 indicating that the resident was not considered by the State to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability or mental retardation or a related condition. A review of Resident 106's clinical record revealed a Level I PASRR was completed on July 27, 2023, by the receiving facility, indicating that the resident did not meet the criteria for a Level II PASRR. A continued review of Resident 106's clinical record revealed a Level I PASRR was completed on July 26, 2023, by the transferring facility, which indicated that the resident met the criteria for a Level II PASRR. A further review of the resident's clinical record, revealed a letter of determination dated June 30, 2023, indicating the resident met the criteria for specialized services. Interview with Employee 6, (Social Services) on November 16, 2023, at approximately 10:20 AM, revealed she was not aware of the existence of either the Level I PASRR dated July 26, 2023, and the letter of determination dated June 30, 2023. Interview with the RNAC (registered nurse assessment coordinator) on November 16, 2023, at approximately 10:25 AM, confirmed that the resident's admission MDS assessment dated [DATE], was inaccurate, with respect to completion of Section A 1500 related to the PASRR. Refer F 644 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 10 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on clinical record review and staff interviews, it was determined that the facility failed to incorporate the recommendations from the Pre-admission Screening and Resident Review (PASARR) level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one of eight residents reviewed (Resident 106). Findings include: Review of Resident 106's clinical record revealed she was admitted into the facility on July 27, 2023, with diagnoses to include alcohol abuse, major depression, conversion disorder with seizures or convulsions, borderline personality (a mental illness that affects how you feel and relate to others), and schizoaffective disorder (a mental health condition that is marked with a combination of hallucinations or delusions, and mood disorder symptoms such as depression or mania). A continued review of Resident 106's clinical record revealed a Level I PASRR was completed on July 26, 2023, by the transferring facility, which indicated that the resident met the criteria for a Level II PASRR. A PASARR Level II determination letter dated June 30, 2023, indicated that, the resident had been determined eligible for the level of services provided by a nursing facility and may be admitted or continue to reside in a nursing facility enrolled in the Department's Medicaid (MA) Program. The nursing facility must provide or arrange for provision of mental health services for any resident with mental illness who needs such services. Such services include: preparation of systematic plans which are designed to facilitate appropriate behavior, drug therapy and monitoring for effectiveness and side effects, structured social activities, the teaching of daily living skills to enhance self-determination and independence, Individual/group/family therapy, and/or personal support networks and formal behavior modification programs as determined by and provided by qualified personnel. Review of Resident 106's current care plan conducted during the survey ending November 17, 2023, revealed no care plan developed in relation to the PASARR II determination. The care plan failed to identify the individual and specific services recommended and/or provided to the resident as the result of the resident's mental health and PASARR II. There was no evidence that specific services were obtained, coordinated or provided based on the resident's PASARR Level II determination letter dated June 30, 2023. Interview with Employee 6, (Social Services) on November 16, 2023, at approximately 10:20 A.M., revealed she was not aware of the existence of either the Level I PASRR dated July 26, 2023, and the letter of determination dated June 30, 2023. An interview with the Nursing Home Administrator (NHA) on November 16, 2023, at approximately 11:10 A.M. confirmed that the PA-PASARR II form completed had identified Resident 106 as a target resident and were unable to provide evidence of coordination of services including care planning. Refer F 641 28 Pa. Code 211.5(f) Medical records (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 11 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0644 28 Pa. Code 201.14 (a) Responsibility of Licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12 (d)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 12 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on a review of the facility assessment, clinical records and calendar of activities programming, observations and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests, preferences, and functional and cognitive abilities of at least six residents out of 30 sampled residents (Residents 15, 47, 58, 105, 111, and 121). Residents Affected - Some Findings include: A review of the facility's Facility Assessment that was last revised by the facility July 2023, revealed that the facility offered a dementia care unit that provides daily dementia specific activities to meet the resident's needs and goals. A review of the November 2023 activities calendar posted the Arcadia Unit, the facility's dementia care unit, indicated that on November 14, 2023, the scheduled 10:00 AM activity was news chronicles and the scheduled 1:30 PM activity was bingo. Observations of the activities scheduled to be performed with the Arcadia Unit residents on Tuesday, November 14, 2023, at 10:35 AM, revealed that the planned activity news chronicles was not conducted with the residents as planned. Further observations of the second floor Arcadia Unit on November 14, 2023, at 10:52 AM, revealed that Resident 121, with a BIMS (Brief Interview of Mental Status-a tool to assess cognitive function score) of 13 (a score of 13-15 indicates intact cognition) approached surveyor and stated, I wish we had more activities on this unit. Continued interview with Resident 121 revealed that the resident stated that over the past 3-months that they {residents residing on the Arcadia Unit} haven't been provided regularly scheduled activities. The resident referred to the posted activities calendar posted outside of their dining/activity room and stated that the scheduled activities were not being conducted with residents. She stated that she liked to color, do crafts, play bingo, and participate in other activities but the activities aren't consistently performed or available to her on that unit. Observations of activities scheduled to be performed on Tuesday, November 14, 2023, at 1:45 AM, revealed that the scheduled activity, bingo, was not conducted on the Arcadia Unit. A review of the first-floor activity schedule for November 2023, revealed that the planned activity on Wednesday, November 15, 2023, at 10:00 AM, was Holiday Craft that entailed residents crafting Christmas ornaments and the planned 10:00 AM craft on the second floor Arcadia Unit was Daily Chronicle. Interview with Resident 121 on November 15, 2023, at 10:10 AM, revealed that she would like to make an ornament and that she used to be able to go to the first floor to attend group activities, but no one has taken her. During a group meeting with five (5) alert and oriented residents (Residents 15, 47, 58, 105, and 111) on November 15, 2023, at 10:15 AM, all five residents in attendance stated that facility needs more activities. Residents 15, 47 and 58 stated that the facility needs more activities geared toward (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 13 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some male residents and activities for residents with higher functioning cognitive abilities. The residents stated that they have brought the lack of variety of activities up at Resident Council meetings in the past without satisfactory resolution to date by the facility. Further review of the facility's activities calendar for November 2023, revealed that some of the scheduled activities were passive recreational activities [are independent activities that involve using little or no physical or mental activity] such as watching television/movies, reading, and coloring] such as Movie Choice, Daily Chronicle, Weekly Menu (Review and Select), Movie and Popcorn, Morning Gathering, and Current Events and activities of daily living (ADLs) [are acts of essential self-care such personal hygiene, grooming, and eating] such as Salon Haircuts, Paint Nails, and Coffee, Tea, and Treat. During an interview with the Director of Activities on November 16, 2023, at approximately 11:15 AM, the employee stated Resident 121 wanders off and that staff cannot conduct activities and supervise a wandering resident at the same time. The activities director stated that the facility does not have sufficient staff to consistently conduct dementia specific resident activities with the residents residing on the Arcadia Unit (dementia care unit). During an interview with the Nursing Home Administrator (NHA) on November 16, 2023, at 1:30 PM, confirmed that activities were not being performed as planned and the facility was not meeting the individual needs of residents for preferred activities and for residents that require dementia specific activities resident on the Arcadia Unit. 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 201.18 (e)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 14 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 select protocol, reports and clinical records and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to timely follow physician orders for implementing prescribed bowel protocol for one resident out of 30 sampled (Resident 106) to promote normal bowel activity to the extent practicable, and failed to follow physicians orders for medication administration for two residents out of 30 sampled (Residents 106 and 110) Residents Affected - Some Findings include: According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine}the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week). The facility policy titled Bowel Protocol, last reviewed by the facility, August 2023, indicated the purpose is to maintain comfort, and avoid complications including impaction and obstruction. Each nurse will review the clinical alerts in PCC (electronic medical record) to identify residents who have not had a bowel movement (BM) in 72 hours (3 days). If the resident has not had a BM in 72 hours (3 days) the licensed nurse will initiate the bowel protocol. Bowel Protocol: Day 3, Milk of Magnesia (MOM) 30 ml, by mouth for 1 dose if no BM in 72 hours, Bisacodyl suppository, administer 1 rectally if MOM ineffective after 8 hours, fleet enema, administer 1 rectally if Bisacodyl suppository ineffective after 8 hours, notify physician if no BM after fleet enema. A review of the clinical record revealed that Resident 106 was admitted to the facility on [DATE], with diagnoses to include, chronic kidney disease (CKD), gastro-esophageal reflux disease (GERD), diaphragmatic hernia, transient ischemic attack (TIA) and cerebral infarction (stroke), and malignant neoplasm of cervix uteri. The resident had physician orders dated July 27, 2023, for the following bowel regimen: Milk of Magnesia (MOM) suspension 400 mg/5 ml give 30 ml by mouth every 24 hours as needed for constipation if no BM for 3 DAYS - if requested instead of suppository on 3-11 shift as needed (PRN). Dulcolax (bisacodyl) suppository 10 mg, insert 1 suppository rectally every 24 hours, PRN, for constipation if no BM on day 3, 3-11 PM shift. Fleet enema 7-19 gm/118 ml, insert 1 dose rectally every 24 hours PRN for constipation, administer Day 4 on 7-3 shift if no results from suppository or MOM PRN. Review of Resident 106's report of bowel activity from the Documentation Survey Report v 2 for August 2023, revealed that the resident did not have a bowel movement on August 3, 4, 5, 6, 7, and 8, 2023. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 15 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the resident's Medication Administration Record (MAR) for August 2023, revealed that on August 7, 2023, day 5 without a BM (bowel movement), milk of magnesia was administered. An order administration note dated August 7, 2023, at 2:37 PM, revealed the resident refused all other interventions, suppository and fleets enema, but agreed to take MOM at this time, which was administered per request. Bowel sounds (BS) active all 4 quadrants. Abdomen soft, nontender, nondistended. There was no documented evidence that nursing timely administered the prescribed bowel protocol during the time period without a bowel movement to promote bowel activity. During an interview with the Regional Nurse Consultant on November 16, 2023, at approximately 11:10 AM, the nurse consultant was unable to provide evidence that physician ordered bowel protocol was timely followed for Resident 106's lack of bowel activity. A review of the clinical record revealed that Resident 110 was admitted to the facility on [DATE] and had diagnoses to include muscle weakness and dementia. Resident 110 had a physicians order for Olanzapine (Zyprexa- used to treat severe agitation associated with certain mental/mood conditions) 2.5 milligrams (mg) once daily. Pharmacy recommendation on October 27, 2023 was to discontinue the Olanzapine. The physician accepted the recommendation on October 31, 2023. Review of Resident 110's Medication Administration Record (MAR) for October and November 2023, revealed the medication was still being administered to the resident until surveyor inquiry on November 16, 2023. Interview with the Director of Nursing on November 16, 2023 at 11:30 a.m. she confirmed that staff continued to administer the medication until November 16, 2023, despite the physician order for its discontinuation noted on October 31, 2023 The Principles of Medication Administration, The Five Rights of Medication Administration indicate that when you are giving medication, regardless of the type of medication, you must always follow the five rights. Each time you administer a medication, you need to be sure to have the: 1. Right individual 2. Right medication 3. Right dose 4. Right time 5. Right route A review of the clinical record revealed that Resident 106 was admitted to the facility on [DATE], (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 16 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with diagnoses to include, fibromyalgia (a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue and sleep disturbance), meralgia paresthetica lower limb (a condition characterized by tingling, numbness and burning pain in your thigh), chronic pain, and malignant neoplasm of cervix uteri. A physician order dated August 21, 2023, was noted for Oxycodone HCL (an opioid pain medication) 5 milligram (mg), give 5 mg by mouth every 4 hours as needed for moderate to severe pain. A facility provided investigation report (IR) dated September 10, 2023, indicated that the wrong dose of Oxycodone HCL 10 mg, was incorrectly given to resident 106, instead of the physician prescribed 5 mg. Employee 16 (Registered Nurse), incorrectly removed the Oxycodone HCL 10 mg, belonging to Resident 148, and administered it to Resident 106 in error, without ill effect to either resident. A review of a nurses note dated September 10, 2023, at 3:23 PM, revealed that the physician was made aware of a medication error with no ill effects had occurred. New orders were obtained, family notified. During an interview with the Director of Nursing (DON) on November 17, 2023, at approximately 10:45 AM, confirmed the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for medication administration. 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 28 Pa. Code 211.5(f) Medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 17 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and staff interview, it was determined that the facility failed to provide restorative nursing services to increase and/or prevent a decrease in range of motion to the extent possible for one resident out of 11 residents sampled (Resident 110). Findings include: A review of the clinical record revealed that Resident 110 was admitted to the facility on [DATE] and had diagnoses to include muscle weakness and dementia. A Physical Therapy Discharge Summary note dated October 2, 2023, revealed Discharge recommendations for Resident 110 were for restorative nursing program (RNP), for lower extremities (LE) active range of motion (AROM) exercises. There was no documentation that resident was provided an RNP from October 2, 2023 until current survey ending November 17, 2023 Interview with the Director of Nursing on November 16, 2023, at 10:30 a.m., she confirmed there evidence of the provision of the recommended RNP to Resident 110. 28 Pa. Code: 211.5(f) Clinical records 28 Pa Code 211.12 (c)(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 18 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of select facility policy and clinical records, resident and staff interviews it was determined that the facility failed to accurately and fully assess residents' ability to safely smoke, provide necessary safety measures and/or supervision to assure safe smoking and prevent accident hazards by four residents out of five residents who smoke (Residents 57, 104, 79, and 113) and failed to adequately supervise a newly admitted resident with wandering behavior to prevent an elopement (Resident 299) out of six residents sampled. Findings included Review of the facility policy titled Smoking Policy - Non Smoking Facility, last reviewed by the facility, August 2023, indicated it is the facility to provide a safe environment for our residents, staff and visitors by providing a smoke free facility. Policy implementation: Referral sources are aware of the facility smoking policy, new admissions shall be informed, no smoking signs shall be prominently displayed throughout the facility where smoking is prohibited. Smoking restrictions shall be strictly enforced in all nonsmoking areas. Staff members and volunteer workers shall not purchase and/or provide smoking articles, the facility may check the residents property/person for such materials. If a resident wishes to change their preferences and smoke, the facility will coordinate through social services a transfer to a smoking facility. Noncompliance could pose significant negative impact on the safety of ALL residents and staff, failure to comply could include discharge from the facility. Violations could include smoking in or on facility grounds, giving smoking materials to other residents. During entrance conference, on November 14, 2023, at approximately 10:15 AM, the Director of Nursing (DON), stated the facility is a non-smoking facility, but that residents leave the facility property, to go up the road, and smoke there. The DON was unable to state who owns the property on which the residents smoke, but she was unable to state. The facility provided a document Smoking Residents, with a list of 5 resident names, which included Resident 137, but also noted, handwritten that facility is non-smoking. A review of the clinical record revealed that Resident 137, was admitted to the facility on [DATE], lack of coordination, repeated falls, and incomplete quadriplegia (weakness or paralysis leading to partial or total loss of function in the arms, legs, truck, and pelvis) of cervical 5 - cervical 7. A review of a nurses note dated June 15, 2023, at 10:04 PM, revealed that the resident stated that he was nauseated throughout the day, that began in morning when he went outside to smoke a cigarette. The resident stated that he isn't going to smoke anymore and declined a nicotine patch at this time. Review of a nurses note dated August 10, 2023, at 8:06 AM, revealed a new order that resident may go leave of absences (LOA) outside of facility-on-facility grounds only independently from 8:00 AM - 8:00 PM, resident made aware of same. A nurses note dated August 12, 2023, at 12:24 AM, indicated that nursing approached resident to administer pain medication and the resident smelled of cigarettes but had not been out of facility. RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 19 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0689 supervisor notified. Level of Harm - Minimal harm or potential for actual harm A nurse's note dated August 12, 2023, at 12:30 AM, revealed that the resident was coming out of bathroom smelling of cigarette smoke. Nurse aides went into bathroom and it smelled of cigarette smoke. The staff called the administrator for suspected smoking in the building. RN supervisor confiscated a half smoked cigarette and lighter from the resident's room. Residents Affected - Some A review of facility quarterly smoking screen, dated August 14, 2023, indicated that the resident does smoke, that he has difficulty using his bilateral hands. It was noted that the resident smokes, not only outside of facility, but in facility shower room as well. He is non-compliant with smoke-free facility policy, resident noted to have difficulty holding on to objects. The screen noted that the smoke free facility-policy should be enforced. A physician order was noted dated August 22, 2023, revealed that may go LOA on facility, and off facility grounds, as long as he signs out at the front desk from 8:00 AM to 8:00 PM. Must be back in building by 8:00 PM. A quarterly Minimum Data Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated August 22, 2023, revealed that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, a score of 13-15, indicates cognitively intact. Nursing documentation dated September 20, 2023, at 9:09 AM, noted that when entering the parking lot at start of shift and coming around hard turn into lot, staff observed the resident sitting (in a wheelchair) in a blind spot for vehicles in the facility's parking lot. The staff member slowed for resident to safely propel self-off the road, but the resident did not do so. Nurse noted twice, staff witnessing residents decreased safety awareness. Staff out to provide safety education to resident, resident not receptive to education according to this nursing entry. A review of the resident's care plan dated October 2, 2023, indicated that the resident is a smoker occasionally non-compliant with rules/policies in place for smoking A review of facility provided document entitled smoking violation review dated October 6, and 25, 2023, indicated a violation had occurred (2 months after the above quarterly smoking screen dated August 14, 2023, had indicated he is known to smoke inside the facility shower room). Nursing documentation dated October 25, 2023, at 8:10 AM, noted that staff saw the resident out in the front of the building under pass, smoking a cigarette. Staff educated the resident at time of finding. Upon returning to unit the resident was educated again on non-smoking facility and smoking policies. Resident verbalized understanding of same. Nursing documentation dated November 8, 2023, at 8:08 AM, revealed that the resident was off the unit when this nurse arrived at facility. Multiple staff witnessed the resident self-propel off facility property and light a cigarette with a lighter he pulled from his pants. Upon returning to unit, staff requested the resident turn in lighter, as he signed paperwork that this is procedure. Resident refused to do so stating that he does not have a lighter. Resident refused to turn in lighter and propelled back to room. social services made aware. Interview with alert, and oriented Resident 137, on November 15, 2023, at approximately 10:55 AM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 20 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed that the resident confirms that he does continue to smoke, outside the facility, up the hill. The resident stated that he is able to smoke between the hours of 8:00 AM and 8:00 PM, at any time, and as frequently as he wishes. Resident 137 stated he has not smoked in approximately 1 week because he is waiting for smoking supplies to be provided by his family. Observation upon leaving the facility on November 15, 2023, at approximately 2:20 PM, the surveyors observed several residents smoking, grouped together on the left upper corner of the property. Upon approach, the surveyor observed four residents, all seated in wheelchairs, and no staff member present. In this group were Residents 57, 79, 104, and 113. After introduction, the surveyor spoke with the resident group. The residents stated that they are free to come outside and smoke between the hours of 8:00 AM to 8:00 PM, even presently with the hour of darkness being approximately 5:00 PM, and cold temperatures, without any staff supervision. During this observation, there were no smoking receptacles present for the residents to safely discard their cigarettes. The residents stated that their smoking materials are kept by nursing. During this observation, Resident 57 was was observed seated in his wheelchair holding his cigarette with the ashes falling, and resting on his clothing, shirt-lap. The resident was not wearing a smoking apron or other protective garment. A review of Resident 57's clinical record, revealed that he was alert and oriented. However, he had not been evaluated for safe smoking and his care did not include smoking. A review of Resident 104's clinical record, revealed she was alert and oriented. Her current care plan, revealed she is a smoker, and is non-compliant with the smoking policy. The care plan noted that staff were to instruct the resident about the policy on smoking, locations, times, and safety concerns. The resident's care plan did not identify where the resident's smoking material are to be stored. A review of facility quarterly smoking screen, dated October 13, 2023, indicated that the resident does smoke, and is non-compliant with smoking policy, that she resides at a non-smoking facility, and the recommendation was no smoking is allowed at this facility. A review of Resident 79's clinical record, revealed that he was alert and oriented. His care plan, revealed he had a history of smoking in the community, and inappropriate smoking related to nicotine dependence staff were to instruct the resident about the policy on smoking, locations, times, and safety concerns. The resident's care plan did not identify where the resident's smoking material are to be stored. A review of facility's quarterly smoking screen, dated October 13, 2023, indicated that the resident does smoke, and is non-compliant with smoking policy. The screen was incomplete when reviewed during the survey ending November 17, 2023. A review of Resident 113's clinical record, revealed that he was severely cognitively impaired, and had diagnoses of cerebral infarction (stroke), aphasia (disorder affecting the comprehension of language or unable to formulate language), and left sided hemiplegia and hemiparesis (weakness of one entire side of the body). His current care plan, revealed that he was a smoker and occasionally non-compliant with rules and policies. Staff were to instruct the resident about the policy on smoking, locations, times, and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 21 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some safety concerns. The resident's care plan failed to identify where the resident's smoking materials are stored. A review of facility quarterly smoking screen, dated October 13, 2023, indicated that the resident does smoke, had a cognitive loss, BIMS of 3, history of stroke, and is non-compliant with smoking policy. This screen was incomplete when reviewed during the survey ending November 17, 2023. On November 16, 2023, at approximately 11:50 AM, Employee 8 (Maintenance Director) measured the distance from the facility's main entrance/exit to the location the survey team observed the group of residents smoking. This paved road, is up a grade - incline, and is located left of a sign identifying the facility, just past a speed bump, and measured 185 feet, on the left, when exiting the facility. Upon observation, the surveyor and Employee 8, noted numerous cigarette butts on the ground, surrounded by dry leaves. During this observation, there were no smoking receptacles present for the residents to safely discard their cigarettes. In questioning, Employee 8 stated this location is on the property belonging to the facility. It was observed, just outside the facility's main entrance, a fire blanket was in a closed box attached to the building, with a glass/plastic face exposing a fire blanket. This fire blanket is located 185 feet from the location the residents were observed smoking. On November 17, 2023, at approximately 9:00 AM, the state survey team observed Resident 104 seated in her wheelchair, unsupervised, in the same location as previously observed on November 15, 2023, smoking a cigarette. At the time the survey ended, November 17, 2023, the facility provided the state survey team aerial maps of the area, county, town, however, was unable to provide the specific ownership of the property, on which the facility residents smoke as described by the DON during entrance conference. During an interview with the Nursing Home Administrator (NHA) on November 17, 2023, at approximately 10:40 AM, confirmed the facility failed to maintain an environment free from potential accident hazards by failing to fully and accurate assess residents' ability to safely smoke and assure necessary staff supervision and/or the use protective safety garments and devices for their smoking residents. A review of a facility policy Elopement that was last reviewed by the facility on August 14, 2023, indicated that it was the policy of the facility to provide a safe and secure environment for all residents. The assessment includes to assess a resident's mental stability, emotional status, and behavior modifications. Staff is educated on the responsibility to identify, report, and intervene related to wandering/elopement risk such as but not limited to, anticipate resident needs based upon wandering triggers and patterns, acknowledge resident's behavior as an attempt to communicate needs, and to encourage verbalization, identify etiology and recognize feelings etc. A review of Resident 299's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia, metabolic encephalopathy sepsis [is a severe neurologic syndrome characterized by a diffuse dysfunction of the brain caused by sepsis, a life-threatening condition resulting from the dysregulated response of the body to an infection], psychotic disturbance [are a group of serious illnesses that affect the mind and make it hard for someone to think clearly, make good judgments, respond emotionally, communicate effectively], and generalized anxiety disorder [is a group of mental illnesses that cause constant fear and worry that are characterized by sudden feeling of worry, fear and restlessness]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 22 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employee 9, a registered nurse (RN), on October 12, 2023, at 12:15 AM, noted an admission assessment of Resident 299 indicating that the resident was alert with confusion to time and place, but was easily reoriented and cooperative. The resident questioned his need to be here {admitted to the facility}. The nursing documentation noted that the resident had a history of sundowners, which had progressed as the evening went on and became more confused and harder to reorient. Employee 9 also noted that the resident transferred himself unassisted to a wheelchair and wheeled himself down to nurse's station and was looking for something to eat. Employee 10, a licensed practical nurse (LPN), on October 13, 2023, at 3:27 AM, noted that the resident self-transferred himself OOB (out of bed) and was at nurses' station at the beginning of the shift looking for his wife, and was easily redirected without adverse behaviors noted at that time. Nurse's progress notes completed by Employee 11, Unit Manager/LPN, dated October 14, 2023, revealed that the resident was alert with confusion per baseline and was wandering the unit walking independently. An elopement incident report that was completed by Employee 11, dated October 16, 2023, at 2:45 PM, revealed that the resident was last seen on the 3rd floor ambulating up and down the hallway and that the resident went out of the front door of the facility and was ambulating down the left side of the sidewalk towards the road. Behavior interventions included re-direction and alternate activity. A call was placed to 911, police arrived on scene down the street from the facility as the resident continued to walk with staff that were accompanying him in attempt to find his home. A review of Employee 11's nurse statement of what happened and other contributing factors, completed at the time of the elopement incident report, revealed that this nurse {Employee 11} was leaving the facility to go to an appointment, I left the building and walked to my vehicle upon attempting to drive out of parking lot I noticed a resident {Resident 299} walking downside walk on left side of building and exiting into the street (Leader Road). I {Employee 11} immediately pulled over and attempted to redirect resident {Resident 299} back to the building. As doing so, I also called other staff from the building (The LPN on the unit where resident resides and a fellow unit manager.) The resident {Resident 299} continued to ambulate down Leader Road towards toward [NAME] avenue. The entire time the resident {Resident 299} and I {Employee 11} were walking I was attempting to redirect resident back to facility. At this time, other staff came to assist this nurse. Resident {Resident 299} was very aggressive and cursing at this nurse, stating I am going to walk into traffic and commit suicide! There is no crime in committing suicide is there, call the police on me! At this time, this nurse called 911 for police assistance/ambulance as resident was threatening to harm himself. We {Resident 299 and Employee 11} continued to walk down Leader Road and made a left onto [NAME] Avenue. This nurse {Employee 11} and fellow staff continued to follow resident while attempted to redirect and calm resident, unsuccessfully, down [NAME] Avenue to [NAME] Street, where we were met by a police officer. The officer exited her vehicle and resident began to escalate cursing and yelling, threatening to hurt himself and others. The officer offered the resident a ride in her vehicle and resident entered her patrol car on his own will. After the police officer closed the door, the resident began punching the window of the patrol car multiple times and screaming at the window. This {Employee 11} and fellow unit manager followed resident and officer an acute care facility where crisis was called and petition for 302 [Involuntary admission (also known as a 302) to an acute inpatient psychiatric hospital occurs when the patient does not agree to hospitalization on a locked inpatient psychiatric unit, but a mental health professional evaluates the patient and believes that, as a result of mental illness, the patient is at risk of harming self or others, or is unable to care for self. The person must pose a clear and present danger to self or others based upon statements and behavior that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 23 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0689 occurred in the past 30 days] was completed. Level of Harm - Minimal harm or potential for actual harm A review of a witness statement completed by Employee 12, a nurse aide, dated October 16, 2023, no time indicated, revealed that she saw Resident 299 get on the elevator, out of the corner of her eye, around 2:40 PM. Employee 12 noted that she told the nurse that she thought that the resident got onto the elevator. Employee 12 also noted that when she went outside, {Resident 299} was in the parking lot with another nurse. Resident 299 stated that he was walking home and stated to take him to jail. He stated that he was going to kill himself. Residents Affected - Some A review of a witness statement completed by Employee 13, front desk receptionist, dated October 17, 2023, no time indicated, revealed that on Monday afternoon around 2:10 PM, that a new resident came in and went to the third floor, also around that time, a resident was being discharged and she was in the lobby and her family was here to pick her up. In the meantime, a nurse came out and asked me if I saw a man {Resident 299} come out here in the lobby with pajamas on. I answered no I did not. Then, a few nurses came and went outside looking for a resident. During an interview with the Nursing Home Administration (NHA) on November 16, 2023, at approximately 1:30 PM, indicated that the 3rd floor staff should have identified Resident 299's increased wandering behaviors and provided increased supervision for safety to prevent elopement. Additionally, the NHA confirmed that Employee 13 failed to ensure that facility's lobby doors were monitored and secured to prevent a resident {Resident 299} with had wandering behaviors from eloping from the facility. Refer F 926 28 Pa. Code (d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 24 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, observation, and staff interview, it was determined that the facility failed to follow physician orders for oxygen therapy and maintain oxygen equipment in a functional and sanitary manner for two residents out of 30 sampled (Residents 14 and 6). Residents Affected - Few Findings include: Clinical record review revealed that Resident 14 had a current physician's order, dated September 1, 2023, for continuous oxygen therapy administration via nasal cannula (flexible plastic tubing with small prongs inserted into the nostrils to deliver supplemental oxygen) at one liter per minute. An observation conducted on November 14, 2023, at 12:40 PM revealed that Resident 14 was lying in bed with supplemental oxygen in place via an oxygen concentrator (bedside machine that concentrates ambient air to supply an oxygen-rich gas stream) with the liter flow set at 2.0 liters per minute. The resident's oxygen tubing was not dated. Additional observation on November 15, 2023, at 11:20 AM revealed Resident 14's was lying in bed with supplemental oxygen tubing in place on his nose however the oxygen tubing was not connected to the oxygen concentrator and the resident was not receiving the prescribed oxygen. The oxygen tubing end was in contact with the floor. The oxygen liter flow was set a 2.0 liters per minute. Clinical record review revealed that Resident 6 had a current physician's order, initially dated January 26, 2023, for continuous oxygen therapy administration via nasal cannula at two liters per minute. An observation conducted on November 14, 2023, at 1:16 PM, and on November 15, 2023, at 11:30 AM revealed that Resident 6 was lying in bed with supplemental oxygen in place via an oxygen concentrator with the liter flow set at 3.0 liters per minute. The oxygen tubing was not dated. Resident 6's oxygen concentrator vent was visibly covered with dust. Interview with Employee 14 (RN Supervisor) on November 15, 2023, at 11:35 AM confirmed that Resident 14's oxygen tubing was not connected to the oxygen concentrator and that Resident 14 was prescribed one liter per minute of oxygen continuously, but the resident was currently receiving 2.0 liters per minute. Employee 14 also confirmed that Resident 6 was prescribed two liters of oxygen continuously, but the resident was currently receiving 3.0 liters per minute. Employee 14 confirmed Resident 6's oxygen concentrator vent was covered with dust. Interview with Nursing Home Administrator on November 16, 2023, at 1:45 PM confirmed the facility failed to follow physician orders for the administration of oxygen and that the condition of the oxygen concentrators was not consistent with facility policy for maintenance of oxygen delivery equipment. 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 25 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, and staff interview, it was determined that the facility failed to provide person-centered care for residents receiving hemodialysis services and ensure the ready availability of necessary emergency supplies for two residents out of three sampled receiving hemodialysis (Resident 69 and 35). Residents Affected - Some Findings include: A review of the clinical record revealed that Resident 69 was admitted to the facility on [DATE], with diagnoses to include diabetes, end stage renal disease and dependence on renal dialysis. Resident 69's clinical record indicated she was receiving hemodialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood), on every Tuesday, Wednesday, Thursday and Saturday. A review of the resident's physician's orders, clinical record and care plan revealed no plans for monitoring the dialysis access site or location of an emergency kit available. Observation conducted on November 16, 2023, at 12:00 PM revealed that there were no emergency supplies at the resident's bedside or on the resident's wheelchair. A review of the clinical record revealed that Resident 35 was most recently admitted to the facility on [DATE], with a diagnosis to include diabetes, end stage renal disease, and dependence on renal dialysis. The resident was receiving hemodialysis on every Monday, Wednesday, and Friday. A review of the resident's clinical record and care plan revealed no plans for the location of an emergency kit available. Observations conducted on November 16, 2023, at 12:10 PM revealed no emergency supplies available at the resident's bedside or on the resident's wheelchair. Interview with Employee 14 (RN Supervisor) on November 16, 2023, at 12:15 PM revealed that each resident in the facility receiving dialysis should have emergency supplies at the bedside and on their wheelchair. Employee 14 confirmed that there were no emergency supplies available at Resident 69 and 35's bedside or wheelchair. Interview with the DON on November 17, 2023, at approximately 9:00 AM confirmed the facility failed to assure emergency kits readily available and physician's orders for care and planning for monitoring of the dialysis access site. 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 26 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. 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 and select reports, observations, and staff interviews, it was determined that the facility failed to fully develop and consistently implement an individualized person-centered plans to address residents' dementia-related behavioral symptoms and provide the necessary care to manage dementia related behaviors for two residents out of 30 sampled residents (Resident 140 and Resident 21). Residents Affected - Some Findings include: A review of Resident 140 was admitted to the facility on [DATE], with diagnoses that included late on-set Alzheimer's dementia and dysphagia (difficulty swallowing) post cerebral vascular accident (stroke). A review of Resident 140's care plan initiated on June 6, 2023, identified that the resident had the potential to be physically aggressive related to anger and dementia and a goal for the resident does not harm self or others, the resident would demonstrate effective coping skills, and the resident would seek out staff/caregiver when agitation occurs. Planned interventions were to analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, administer medications as ordered and monitor/document the effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits, and assess when the resident becomes agitated: intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and if the response is aggressive, staff to walk calmly away, and approach later. The resident's care, dated August 1, 2023, and revised on September 18, 2023, identified that the resident has a behavior problem related to Alzheimer's such as places self on floor, reaching over nurses' station, attempting to throw computer/laptops, throwing water cups with interventions to intervene as necessary to protect the rights and safety of others, encourage activity participation, and monitor behaviors related to use of psychotropic medication, Risperdal. Resident 140's quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment dated [DATE], revealed that she had severe cognitive impairment and frequently had physical and verbal behavioral symptoms towards other residents, and exhibited wandering behavior. A review of Resident 140's nursing progress notes from her initial admission through survey ending November 17, 2023, revealed that the resident exhibited aggressive, threatening, and abusive behaviors towards other residents and staff members such throwing large objects (computer screens, laptops, shoes, and supplies), punching, slapping, yelling, cursing, wandering, and exit seeking. Resident 140 had three instances of physical resident-to-resident altercations and was the aggressor at each altercation (the October 6, 2023, altercation was with 1:1 staff supervision present). Observations during survey that began on November 14, 2023, and ended on November 17, 2023, revealed that Resident 140 was observed wandering about the unit and displaying intrusive behaviors with other cognitively impaired residents. There was no evidence that the facility had implemented an individualized person-centered plan to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 27 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0744 address, modify, and manage Resident 140's dementia-related behaviors. Level of Harm - Minimal harm or potential for actual harm The resident's care plan for behavioral symptoms failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in effort to manage the resident's dementia-related behavioral symptoms to promote the resident's psychosocial well-being. Residents Affected - Some Interview with the Nursing Home Administrator (NHA) on November 16, 2023, at 1:25 PM, confirmed that the facility failed to fully develop and implement a dementia-care plan that included specific interventions to manage Resident 140's behaviors. A review of Resident 21's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included unspecified dementia, cognitive communication deficit [is a difficulty with communication that is caused by a cognitive impairment], and chronic kidney disease [is a condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic and disease progression occurs slowly over time]. A review of the resident's quarterly MDS assessment dated [DATE], revealed that the resident had sever cognitive impairment and frequently exhibited the presence of physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred one to three days, and verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occurred four to six days and wandering. A review of Resident 21's plan of care initiated on December 2, 2022, identified that the resident had potential to be verbally and physically aggressive towards staff and other residents related to diagnosis of dementia with planned interventions to analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document, intervene before agitation escalates and guide away from source of distress, and to offer activities as diversion with increased behaviors such as coloring, card games, or crossword puzzles. A review of Resident 21's clinical record through survey ending November 17, 2023, revealed that she was the aggressor in verbal and physical incidents with other cognitively impaired residents and staff members. Additionally, the clinical record revealed that the resident exhibited aggressive, threatening, and abusive behaviors towards other residents and staff members. Observations during survey that began on November 14, 2023, and ended on November 17, 2023, revealed that Resident 21 was observed wandering about the unit and displaying intrusive behaviors with other cognitively impaired residents. The facility failed to develop and implement an individualized person-centered plan to address, modify, and manage Resident 21's dementia-related behaviors. The resident's care plan for behavioral symptoms failed to include individualized interventions based on an assessment of the resident's preferences, social/past life history, customary routines, and interests in effort to manage the resident's dementia-related behavioral symptoms to promote the resident's psychosocial well-being. The facility failed to demonstrate the use of qualified staff that demonstrate the competencies and skills to support residents through the implementation of individualized approaches to care, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 28 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some including direct care and activities, that are directed toward understanding, preventing, relieving, and/or accommodating the residents' distress or loss of abilities. Interview with the Nursing Home Administrator (NHA) on November 16, 2023, at 1:28 PM, confirmed that the facility failed to fully develop and consistently implement care and services to treat the resident's dementia related behaviors. Refer F679 28 Pa Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 29 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and controlled drug records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate administration, and records accounting for controlled drugs for one of two residents sampled (Resident 106). Findings include: A review of the clinical record revealed that Resident 106 was admitted to the facility on [DATE], with diagnoses to include, fibromyalgia (a disorder that affects muscle and soft tissue characterized by chronic muscle pain, tenderness, fatigue and sleep disturbance), meralgia paresthetica lower limb (a condition characterized by tingling, numbness and burning pain in your thigh), chronic pain, and malignant neoplasm of cervix uteri. A physician order dated August 21, 2023, was noted for Oxycodone HCL (an opioid pain medication) 5 milligram (mg), give 5 mg by mouth every 4 hours as needed for moderate to severe pain. The facility provided narcotic controlled medication record, accounting for Resident 106's supply of Oxycodone 5 mg, revealed that on September 4, 2023, 11:40 AM), a dose was given, amount remaining 53, on September 7, 2023, at 0600 (6:00 AM), a dose was given, amount remaining 49, and on September 9, 2023, at 1600 (4:00 PM), one dose given, amount remaining 46. A review of the Medication Administration Record (MAR), for September 2023, revealed Oxycodone HCL 5 mg, give 5 mg by mouth every 4 hours as needed for moderate to severe pain. However, according to the resident's September 2023 MAR on September 4, 2023, no dose, of Oxycodone HCL 5 mg, was given to the resident on that date. According to the resident's September 2023 MAR on September 7, 2023, no Oxycodone HCL 5 mg, was given at 6:00 AM or on September 9, 2023. The facility failed to implement procedures to promote accurate administration and records of controlled substance medication and to deter the potential for drug diversion. During an interview with the Director of Nursing (DON) on November 17, 2023, at approximately 10:45 AM, confirmed that the controlled drug record and MARs should match, and that her expectation is that the controlled substance and clinical record accurately reflect the medication accounting/controlled drug use and administration to the resident. 28 Pa. Code 211.19 (a)(1)(k) Pharmacy services 28 Pa. Code 211.12 (d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 30 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the physician failed to act upon drug irregularities in the drug regimen of one resident out of five sampled (Resident 21). Findings included: A review of Resident 21's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included unspecified dementia, cognitive communication deficit [is a difficulty with communication that is caused by a cognitive impairment], and chronic kidney disease [is a condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic and disease progression occurs slowly over time]. A physician's order dated June 19, 2023, at 10:55 AM, was noted for ABH gel (0.5mg Ativan /25mg Benadryl/0.5mg/ Haldol Gel) [is a compound that is made up of lorazepam, diphenhydramine, and haloperidol that is prescribed for individuals in hospice and palliative care settings for the treatment of nausea and vomiting and terminal delirium/agitation] every four hours PRN (as needed) for agitation/anxiety for seven days, then psych services to reassess. A review of a Note to Attending Physician/Prescriber that was completed by the consultant pharmacist on June 22, 2023, at 1:08 PM, indicated that on June 19, 2023, the resident was prescribed PRN ABH Gel for agitation/anxiety. The resident was noted to have had a urinary tract infection [(UTI) is an infection in any part of the urinary system that can cause confusion, delirium, and agitation/behaviors] around the same time that her behaviors increased. The pharmacist recommended the physician discontinue or provide clinical justification for continued use of the medication. A review of the attending physician's response dated June 28, 2023, noted solely no UTI, urine culture - no growth. Resident 21's clinical record failed to reveal that the attending physician documented in the resident's medical record what, if any, action has been taken to address the identified irregularity. The attending physician failed to document the clinical rationale for making no change in the medication in resident's medical record to include clinical justification for the continued use of antipsychotic medication, ABH Gel. In an interview with the Director of Nursing (SON), on November 16, 2023, at approximately 1:45 PM, confirmed that the facility failed to ensure that Resident 21's attending physicians provided clinical justification/rationale for the continued administration of antipsychotic medication. Refer F758 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 31 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued administration of an antipsychotic medication for one resident out of five sampled residents for unnecessary medication use (Resident 21). Findings included: A review of Resident 21's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to have included unspecified dementia, cognitive communication deficit [is a difficulty with communication that is caused by a cognitive impairment], and chronic kidney disease [is a condition characterized by a gradual loss of kidney function. Early stages can be asymptomatic and disease progression occurs slowly over time]. A review of a Note to Attending Physician/Prescriber that was completed by the consultant pharmacist on January 27, 2023, at 2:14 PM, identified that Resident 21 had an order for Seroquel [an antipsychotic medication is used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) and contradicted for the elderly] 12.5 mg every HS (at bedtime) and indicated that the medication was due for assessment in accordance with CMS guidelines for psychopharmacological medications. If no dose reduction (GDR) is indicated, please include a brief patient specific rationale. A review of the attending physician's response dated January 30, 2023, failed to include a resident specific rationale to justify the continued use of the antipsychotic medication, Seroquel. A Note to Attending Physician/Prescriber that was completed by the consultant pharmacist on April 28, 2023, continued to identify Resident 21's irregular use of Seroquel 12.5 mg every HS (at bedtime) and indicated that the medication was due for assessment in accordance with CMS guidelines for psychopharmacological medications. If no dose reduction (GDR) is indicated, please include a brief patient specific rationale. A review of the attending physician's response dated May 5, 2023, failed to include a resident specific rationale to justify the continued use of the antipsychotic medication, Seroquel. A review of Resident 21's clinical record nursing progress notes dated June 19, 2023, at 10:06 AM, revealed that when the nurse attempted to administer AM medications that the resident spit them out and had increased behaviors during that shift. Psychiatric services assessed the resident and attending physician was notified of behaviors and psych recommendations. A physician orders dated June 19, 2023, at 10:55 AM, was noted for ABH gel (0.5mg Ativan /25mg Benadryl/0.5mg/ Haldol Gel) [is a compound that is made up of lorazepam, diphenhydramine, and haloperidol that is prescribed for individuals in hospice and palliative care settings for the treatment of nausea and vomiting and terminal delirium/agitation] every four hours PRN (as needed) for agitation/anxiety for seven days, then psych services to reassess. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 32 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of a Note to Attending Physician/Prescriber that was completed by the consultant pharmacist on June 22, 2023, at 1:08 PM, indicated that on June 19, 2023, the resident was prescribed a PRN ABH Gel for agitation/anxiety. The resident was noted to have had a urinary tract infection [(UTI) is an infection in any part of the urinary system that can cause confusion, delirium, and agitation/behaviors] around the same time that her behaviors increased. The pharmacist recommended that the physician discontinue or provide clinical justification for continued use of the medication. A review of the attending physician's response dated June 28, 2023, noted no UTI, urine culture - no growth. A review of Resident 21's clinical record Medication Administration Record (MAR) date June 2023, revealed that she received eight (8) doses of the PRN ABH gel, an antipsychotic medication. The resident's July 2023 MAR revealed that she received nine (9) doses of the PRN ABH gel, an antipsychotic medication. The physician failed to provide documented clinical justification for the use of a PRN antipsychotic medication without an indicate stop date. In an interview with the Director of Nursing (DON), on November 16, 2023, at approximately 1:45 PM, confirmed that the facility failed to ensure that Resident 21's attending physician provided clinical justification/rationale for the continued administration of antipsychotic medication. Refer F756 28 Pa. Code 211.9 (k) Pharmacy services. 28 Pa. Code 211.12 (c) Nursing services. 28 Pa. Code 211.2 (d)(3) Medical Director FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 33 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of select facility policy and resident and staff interviews, it was determined that the facility failed to routinely offer bedtime snacks as desired to include five alert and oriented residents (Residents 15, 47, 58, 105, and 111). Findings include: Review of the facility's policy, titled Snacks (Between Meal and Bedtime) last reviewed by the facility August 14, 2023, indicated that the purpose is to provide the resident with adequate nutrition. During a group interview with five alert and oriented residents on November 15, 2023, at 10:00 AM, all five residents (Residents 15, 47, 58, 105, and 111) in attendance stated that snacks are not routinely offered to them in the evenings. The residents stated they would like to receive an evening/bedtime snack. During an interview with the Nursing Home Administrator on November 16, 2023, at approximately 10:25 AM, he was unable to explain why the residents were not routinely provided with a bedtime/evening snack. 28 Pa. Code 211.12 (d)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 34 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records and select facility policy, observation, resident, and staff interview, it was determined that the facility failed to implement procedures for smoking safety and safety of smoking areas as evidenced by five out of five sampled residents who smoke (Resident 137, 113, 104, 79, and 57). Residents Affected - Some Findings include: Review of the facility policy titled Smoking Policy - Non Smoking Facility, last reviewed by the facility, August 2023, indicated it is the facility to provide a safe environment for our residents, staff and visitors by providing a smoke free facility. Policy implementation: Referral sources are aware of the facility smoking policy, new admissions shall be informed, no smoking signs shall be prominently displayed throughout the facility where smoking is prohibited. Smoking restrictions shall be strictly enforced in all nonsmoking areas. Staff members and volunteer workers shall not purchase and/or provide smoking articles, the facility may check the residents property/person for such materials. If a resident wishes to change their preferences and smoke, the facility will coordinate through social services a transfer to a smoking facility. Noncompliance could pose significant negative impact on the safety of ALL residents and staff, failure to comply could include discharge from the facility. Violations could include smoking in or on facility grounds, giving smoking materials to other residents. During entrance conference, on November 14, 2023, at approximately 10:15 AM, the Director of Nursing (DON), stated the facility is a non-smoking facility but stated that leave the facility property to smoke. The DON stated that the residents go up the road, and smoke there. The DON was unable to state who owned the property on which the residents smoke and whether the facility owns that property that is the designated smoking area. The facility provided a document Smoking Residents, listing 5 resident names and a handwritten indicating that the facility is non-smoking. A facility quarterly smoking evaluation - screen of Resident 137 dated August 14, 2023, indicated that the resident does smoke, that he has difficulty using his bilateral hands, and the resident noted to smoke not only outside of facility but in facility shower room as well. He is non compliant with smoke free facility policy, resident noted to have difficulty holding onto objects. The screen did not identify the level of supervision the resident required. The evaluation noted that smoke - free facility policy should be enforced, or whether any adaptive equipment is required, for safe smoking. A review Resident 137's care plan plan indicated that the resident is a smoker occasionally non-compliant with rules/policies in place for smoking, dated October 2, 2023. The care plan did not include specific times to smoke, or restriction of times, and or any equipment the resident required for safe smoking. A quarterly smoking evaluation - screen, dated November 14, 2023, indicated the resident does smoke, has cognitive loss (memory loss), multiple infractions involving smoking, refusing to return smoking items, and the recommendations (level of supervision) is that the resident not be permitted to smoke. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 35 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some When the surveyors were leaving the facility on November 15, 2023, at approximately 2:20 PM, team observed several residents smoking, grouped together on the left upper corner of the property. Four residents, Residents 57, 79, 104 and 113, were seated in wheelchairs, and no staff member were present. Interviews with the residents at this time revealed that the residents stated that they free to come outside and smoke between the hours of 8:00 AM to 8:00 PM, even during the current season, with the hour of darkness being approximately 5:00 PM, and colder temperatures. The residents stated that no staff supervision is needed or provided. During this observation, there were no smoking receptacles present in area for the residents to safely discard their cigarettes. The residents stated indicated that their smoking materials (cigarettes, lighters etc.) are kept by nursing. During this observation, Resident 57 was observed seated in his wheelchair holding his cigarette with the ashes falling, and resting on his clothing, shirt-lap. A review of Resident 57's clinical record, revealed he is alert and oriented. However, a smoking evaluation screen, had not been completed, and that his care plan failed to address smoking. A review of Resident 113's clinical record, revealed he is severely cognitively impaired and had left sided hemiplegia and hemiparesis (weakness of one entire side of the body). His current care plan, revealed that he is a smoker, and is occasionally non-compliant with rules policies. The resident's care plan did not identify the location of the resident's smoking material, the level of supervision required, times to smoke, restrictions of times, and if any equipment is required for safe smoking. A quarterly evaluation - screen, dated October 13, 2023, indicated that the resident does smoke, has a cognitive loss, BIMS of 3, history of CVA (stroke), and is non-compliant with smoking policy. The screen was not completed whereas it failed to include smoking recommendations (level of supervision required), and or the need of any adaptive equipment for safe smoking. A review of Resident 104's clinical record, revealed that she was alert and oriented. Her current care plan revealed she is a smoker, and is non-compliant with the smoking policy. Staff were to instruct the resident about the policy on smoking, locations, times, and safety concerns. However, failed to identify where the smoking material is to be stored, level of supervision required, and or equipment needed for safe smoking. A facility quarterly smoking evaluation - screen, dated October 13, 2023, indicated that the resident does smoke, and is noncompliant with smoking policy, that she resides at a non-smoking facility, and recommendations were noted as she resides in a non smoking facility, without identifying the level of supervision required to smoke safely. A review of Resident 79's clinical record, revealed that he was alert and oriented. His current care plan revealed he had a history of smoking in the community and inappropriate smoking related to nicotine dependence. The resident's care plan did not identify where the smoking material is to be stored, supervision required, times of smoking, restriction of times, and equipment required, for safe smoking. A review of facility quarterly evaluation - screen, dated October 13, 2023, indicated that the resident does smoke, and is non-compliant with smoking policy. The screen was incomplete, failing to include the smoking recommendations (level of supervision required), and or the need of any adaptive equipment for safe smoking. On November 16, 2023, at approximately 11:50 AM, Employee 8 (Maintenance Director) measured the distance from the facility's main entrance/exit to the location the survey team observed the group of residents smoking. This paved road, is up a grade - incline, and is located left of a sign identifying the facility, just past a speed bump, and measures 185 feet, on the left, when exiting the facility. Upon observation, this surveyor and Employee 8, noted numerous cigarette butts on the ground, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 36 of 37 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 395344 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901 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 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some surrounded by dry leaves. During this observation, there were no smoking receptacles present for the residents to safely discard their cigarettes. During interview at this time, Employee 8 stated this location is on the property belonging to the facility. It was observed, just outside the facility's main entrance, a fire blanket was observed in a closed box attached to the building, with a glass/plastic face exposing a fire blanket. This fire blanket was located 185 feet from the location the residents were observed smoking by survey team. On November 17, 2023, at approximately 9:00 AM, the state survey team observed Resident 104 seated in her wheelchair, unsupervised, in the same location as previously observed on November 15, 2023, smoking a cigarette. At the time the survey ended, November 17, 2023, the facility provided the state survey team aerial maps of the area, county, town, however, but failed to show specific ownership of the smoking area property, where the facility allows their residents to smoke and as described by the DON during entrance conference. During an interview with the Nursing Home Administrator (NHA) on November 17, 2023, at approximately 10:40 AM, confirmed that the facility was aware of the identified residents smoking outside the front entrance of the facility, just up the road, and confirmed that the residents indicated above did not have either a smoking care plan, and or fully developed care plan, and that the facility did not have completed smoking evaluations - screens, on the residents as stated above, to ensure safe smoking and safe smoking areas as stated in the facility policy. Refer F689 28 Pa. Code 201.18 (b)(1)(e)(1)(2.1) Management 28 Pa. Code 209.3 (a)(c) Smoking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 37 of 37