Health inspection·January 18, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm A review of a nurses note dated December 28, 2023, at 10:32 PM indicated the resident had + 1 pitting edema noted to calves. An MDS review note dated January 3, 2024, at 4:28 PM, indicated that the resident reports that she gets short of breath (SOB) when she lies flat in bed. Residents Affected - Few Nursing documentation dated January 8, 2024, at 1:11 PM, revealed that the resident's daughter planned to pick up the resident tomorrow, January 9, 2024, for discharge home. Nursing documentation dated January 9, 2024, at 10:40 AM, indicated that the resident's family expressed concern regarding the resident's edema to the legs and left arm. The entry noted that nursing staff examined the resident, while the resident was lying in bed. The resident stated they're swollen, especially after I sit in my chair. Nursing instructed the resident to elevate extremities while in bed. Nursing noted that the resident's lungs were clear, abdomen (ABD) within normal limits. + 1 bilateral lower leg edema was present and the resident denies shortness of breath (SOB). Nursing documentation dated January 9, 2024, at 12:21 PM indicated that the resident's daughter was at the facility to pick up the resident for discharge and again expressed more concerns regarding the resident's edema. Nursing made the in house physician assistant notified, according to the nursing entry. A nursing note dated January 9, 2024, at 12:32 PM, indicated that the physician assistant saw the resident and a new order was noted to send the resident home with oxycodone (a narcotic opioid medication) tablets. Nursing documentation dated January 9, 2024, at 12:40 PM, indicated that the resident was discharged from the facility. There was no documented evidence that the consulted with the resident's physician of the resident's significant weight gain and persistent edema and had informed the resident's representative of the resident's 27 lb weight gain in less than one week, from January 3, to January 9, 2024. Interview with Employee 5, Physician Assistant (PA-C), via phone on January 18, 2024, at approximately 3:20 p.m., revealed that the PA-C stated that she was not aware of Resident CR 4's significant weight gain. She stated that she recalled hearing nursing staff's conversations questioning the proper functioning of scales (on the 3rd floor). Interview with the Director of Nursing (DON) on January 18, 2024, at approximately 3:28 p.m., confirmed that there was no evidence that the facility had timely consulted with the resident's physician and notified the resident's representative of the resident's significant weight gain. Refer F711 28 Pa Code 211.12 (c)(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 2 of 16 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 01/18/2024 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on a review of clinical records, the facility's abuse prohibition policy and information submitted by the facility and staff interview it was revealed the facility failed to provide evidence that all instances of alleged resident abuse were thoroughly investigated, the facility's efforts to protect residents from further potential abuse during the course of an investigation, any corrective action taken and submission of the results of all investigation to the State Survey Agency within five working days of the incident as evidenced by 14 of 16 allegations of abuse reviewed (Residents 129, 100, 86, 97, 88, 66, 75, 105, CR2, 84, 90, 76, 81, and Resident 70) Residents Affected - Some Findings include: A review of the current facility policy entitled Abuse Policy-Pennsylvania indicated abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported per federal and state law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown origin, misappropriation of property are reported immediately, but no later than two hours after the allegation is made. Employees must always report ay abuse or suspicion of abuse immediately to the administrator of the facility and other officials, including the state survey agency. The facility procedure for external reporting indicated if an incident or allegation is considered reportable, the administrator or designee will make an initial, an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the state agency within five (5) working days. When making a report, the following information should be reported to include but not limited to: law enforcement reporting would be reported within two hours after forming suspicion if the event that causes the suspicion results in serious bodily injury, or no later than 24 hours if the events that caused the suspicion do not result in serious bodily injury. Within five (5) working days of the incident, the facility will provide in its report sufficient information to describe the results of the investigation and indicate any corrective actions taken if the allegations were verified. A review of incidents of alleged abuse, neglect and misappropriation of property, the facility reported the incident to the State Survey Agency via the Electronic Reporting System (ERS) within the last three months revealed that the facility failed to report the findings and potential corrective actions of the following allegations of abuse, by submitting completed a PB22 (Pennsylvania Bulletin 22- form used to detail investigation, findings and actions) within five (5) working days of occurrence: On November 16, 2023 the facility became aware of an alleged misappropriation of resident's property. Resident 129 alleged a nurse aide, Employee 2, asked him for money. The facility notified the State Agency via ERS on November 28, 2023, and did not submit the PB22 until December 11, 2023. On November 24, 2023, Resident 100 bit Resident CR 1 on the great toe. The facility did not submit the PB22 until December 12, 2023. On November 30, 2023, Resident 86 hit Resident 97 on the back of the head three times. The PB22 was not submitted until December 12, 2023. On November 30, 2023, Resident 97 hit Resident 88 on the shoulder who in return retaliated by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 3 of 16 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 01/18/2024 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 0610 hitting back. The PB22 was not submitted until December 28, 2023. Level of Harm - Minimal harm or potential for actual harm On December 6, 2023, Resident 66 hit Resident 75's leg with a reacher stick. The PB22 was not submitted until January 5, 2024. Residents Affected - Some On December 10, 2023, Resident 100 hit Resident 105 on the wrist. The facility did not report to the State Agency until December 12, 2023, and the PB22 was not submitted until January 8, 2024. On December 21, 2023, Resident CR2 hit Resident 100 with a closed fist and yelled at her. Facility reported via ERS on December 23, 2023, and the PB22 was not submitted until January 11, 2024. On December 30, 2023, Resident 84 hit Resident 90 and in return Resident 90 kicked Resident 84. The PB22 was not submitted until January 14, 2024. On December 16, 2023, Resident 86 grabbed Resident 90's thumb and twisted it. The PB22 was not submitted until January 14, 2024. On December 28, 2023, Resident 76 was observed in Resident 81's room and was escorted out, later Resident 76 went back to Resident 81's room and hit her in the left shoulder. The facility reported via ERS on December 30, 2023, and the PB22 was not submitted until January 14, 2024. On December 28, 2023, Resident CR2 punched Resident 105 in the arm and cursed at her. The PB22 was not submitted until January 15, 2024. On December 4, 2023, Resident 70 was being transferred by nurse aide Employee 3 when the resident fell ad sustained a fractured hip. The event was not reported via ERS until December 6, 2023, and the PB22 was not submitted until January 11, 2024. Local law enforcement was not notified as of January 19, 2024, due to the resident's serious bodily injury. Correspondence with the nursing home administrator (NHA) on January 4, 2024, revealed the State Agency requested the outstanding events of alleged abuse be addressed and requested that the NHA submit, with proper agency notifications that may be required and applicable witness statements, regarding the specific events that were not fully investigated. The NHA stated he was pushing the director of nursing (DON) to complete them. He stated the DON showed him a pile. He stated he would work on them over the weekend. The State Survey sent another email to the NHA on January 8, 2024, asking to that the facility review, complete and submit the outstanding events and completed investigations. On January 11, 2024, the State Survey agency emailed NHA to again request that NHA address the seven outstanding allegations of abuse, dated back to December 16, 2023. The NHA responded to the State Survey agency by stating his DON was off until January 22, 2024. As directed by the NHA the acting DON and unit managers were assisting with the events and the annual survey plan of correction. The NHA stated he would keep the 2024 events current. On January 17, 2024, the State Survey Agency once again requested that the NHA address the outstanding abuse investigations and he responded to the State Survey Agency by stating that he was not in the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 4 of 16 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 01/18/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the State agency ERS revealed that the facility repeatedly failed to submit the results of completed investigations into the above instances of alleged resident abuse to the State Survey Agency (PB22s) within 5 working days of the occurrence. The facility failed to provide evidence of timely and complete investigations into the instances of resident abuse and submission of completed investigations to the State Survey Agency within five working days of the occurrence. 28 Pa. Code 201.14 (a)(c)Responsibility of Licensee 28 Pa. Code 201.18 (e)(1) Management 28 Pa. Code 201.29 (a)(c) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 5 of 16 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 01/18/2024 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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select incident reports and information submitted by the facility and staff interview it was determined that the facility failed to develop and implement a resident's person-centered comprehensive care plan in a manner that assures staff are aware of the resident's specific transfer needs to meet the objective of safe transfers, to prevent a fall with a serious injury, a left hip fracture, for one resident out of four sampled (Resident 70). Findings included: A review of Resident 70's clinical record revealed that the resident had diagnoses of a left leg above the knee amputation, cerebral infarction (stroke), muscle weakness, lack of coordination, abnormalities of gait and mobility, abnormal posture, and left femur (leg) fracture. The resident had an above the knee amputation. The resident's care plan, dated August 31, 2022, identified that the resident had activities of daily living (ADL) self-care performance deficit related to weakness, recent surgery, decrease mobility, cerebral infarction, absence of left leg above the knee and required the assistance of 1 staff to reposition in bed, but was independent with rolling. The resident's care plan also noted that the resident had an acquired absence of left leg above knee with interventions to use a draw sheet or lifting device to move resident, initiated September 01, 2022. Resident 70's care plan, dated September 15, 2023, indicated that the resident required restorative programs related to an unsteady gait with interventions noted as transfer - minimum assist of 1 for transfer with prosthetic on, and moderate assist of 1 without prosthetic. The care plan did not define moderate assistance of one staff and how it differed from minimum assistance of one staff. A review of the resident care [NAME] (a quick reference guide used to inform staff of the resident's care needs and staff tasks) dated December 4, 2023, revealed Resident Care; use a draw sheet or lifting device to move resident, Bed mobility; the resident requires assistance of 1 staff to reposition in bed; independent with rolling, Nursing Rehab / Restorative; Restorative - transfer, minimum assist of 1 for transfer with prosthetic on, and moderate assist of 1 without prosthetic, Transferring; the resident requires assist of 1 for bed/wheelchair modified transfer when wearing prosthetic. A nurse's note dated December 4, 2023, at 2:20 PM revealed that staff found the resident sitting on his buttocks facing the bed on the floor of his room. The resident was wearing a non-skid sock to his right lower extremity (RLE). At the time of the fall, one nurse aide was assisting the resident with a transfer. The resident denied hitting his head. The resident was holding his left hip with discomfort and he stated, I was transferring to weight chair and lost my balance. Nursing assessed the resident for injuries and no injuries were noted. The resident voiced complaints of left hip pain and Tylenol was administered. According to information dated December 4, 2023, submitted by the facility indicated that the resident was not wearing his prosthetic at the time of the above fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 6 of 16 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 01/18/2024 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 0656 Level of Harm - Actual harm Residents Affected - Few A nurses note dated December 4, 2023, at 3:53 PM indicated that the physician assistant was in the facility to see the resident. The resident was complaining of left hip pain. A new order was noted for an x-ray of the left hip. Nursing documentation dated December 5, 2023, at 3:49 AM noted the results of the x-ray as a left hip fracture. Ortho consult in the AM, and non-weight bearing at all times. The resident was educated on non-weight bearing. Nursing noted on December 5, 2023, at 9:46 PM, that the resident was admitted to hospital with left femoral head fracture with impaction. Nursing noted on December 8, 2023, at 10:45 PM that the resident was readmitted to facility after left hip surgery related to fracture. The incident report (IR) entitled fall, dated December 4, 2023, noted the predisposing factor was gait imbalance during transfer. The root cause was identified that he lost his balance transferring to chair for weight. The intervention was to ensure caution by staff with assists during transfer to and from weight chair. The facility failed to identify the level of staff assistance required with transfers to prevent recurrence. A review of information dated December 4, 2023, submitted by the facility indicated the resident fell to the floor during a transfer from bed to a chair to be weighed with a nursing assistant present. The resident was admitted with a left femoral head impacted fracture. The care plan was being followed regarding transfer status and restorative nursing program. His transfer status was minimum assist of 1 staff when his prosthetic is on, and moderate assist of 2 when he does not have his prosthetic is on. During the transfer, the resident did not have his prosthetic on, he refused and wanted to transfer with the assist of 1 staff member. The facility indicated in this report that the resident's care plan was being followed, and indicated that his transfer status was minimum assist of 1 staff when his prosthetic is on, and moderate assist of 2 when he does not have his prosthetic is on, however the resident was being transferred with the assist of 1 staff member and was not wearing his prosthetic. The resident's care plan, in effect at the time of this fall, did not specify the moderate assist of two when he does not have his prosthetic on. The resident's care plan and care [NAME] in effect at the time of the fall indicated both noted minimum assist of 1 for transfer with prosthetic on, and moderate assist of 1 without prosthetic. A review of Employee 3, a nurse aide, witness statement dated December 4, 2023, revealed the aide brought the chair into the resident's room in order to weigh him. The resident was in bed, stood, pivoted, and lost his balance falling to the floor onto his left hip. During an interview with Employee 3, on January 18, 2024, at approximately 2:10 PM, she confirmed that she was alone in the resident's room without other staff members to assist with Resident 70's transfer. Employee 3 further stated she was unaware of the resident's transfer status and had looked at his care plan or [NAME], but other staff members told her that he was independent (no help required). Employee 3 stated that the resident did not refuse additional staff assistance (2nd staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 7 of 16 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 01/18/2024 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 0656 member) and Employee 3, did not ask for additional assistance because he was independent. Level of Harm - Actual harm A review of facility provided document entitled Employee Education/Counseling Form date of incident December 4, 2023, indicated that Employee 3's transfer of Resident 70 from bed to scale was improperly performed, and to check the transfer status of the residents prior to transferring which is found in the [NAME]. Date signed January 18, 2024, during the survey ending January 18, 2024. Residents Affected - Few The facility failed to accurately identify the resident's transfer status and needs on the resident's care plan and care [NAME] to ensure staff awareness of the level of assistance the resident required, both while wearing the prosthetic device on his lower leg and when not wearing the prosthesis. During an interview on January 18, 2024, at approximately 3:00 PM, the DON confirmed facility failed to fully develop and implement person-centered comprehensive care plan in a manner that assures staff are aware of the resident's specific transfer needs under varied situations to meet the individualized safety needs to prevent this fall with serious injury to the resident. 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 8 of 16 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 01/18/2024 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, observation, 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 the residents on the Arcadia Unit (dementia care unit). 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. Observation of the activities calendar posted on the wall in the Arcadia Unit on January 18, 2024, at 11:25 AM revealed the scheduled activities for the day included: Baby Animal Match at 10:00 AM; EZ Name That Tune at 11:00 AM; Meals of Choice at 1:30 PM; Dice Snowmen at 3:00 PM; and Adult Coloring at 4:30 PM. Further observation revealed 12 residents in the activity/lounge area. The television was on but the scheduled 11:00 AM activity was not occurring, and an activities aide was not present on the unit at the time of the observation. During an interview with employee 1 (LPN) on January 18, 2024, at 11:30 AM, the employee confirmed that there was not an activities aide on the unit and that the scheduled activities at 10:00 AM and 11:00 AM did not occur. Employee 1 (LPN) confirmed that the residents do enjoy activities when they occur. Review of the activities department schedule for the date of the survey revealed that an activities aide was not scheduled for the Arcadia Unit on that date. Interview with the director of nursing (DON) on January 18, 2024, at 1:00 PM confirmed that on the date of the survey, activities were not being performed as planned on the dementia care unit due to not having enough activities staff scheduled. The DON also confirmed that dementia specific activities for the residents residing on the Arcadia Unit (dementia care unit) were to be offered as scheduled on the posted calendar. The DON failed to provide documented evidence that activities staff were being scheduled in a manner to ensure sufficient staff were present to conduct dementia specific resident activities with the residents residing on the Arcadia Unit. 28 Pa. Code 201.29 (a) Resident rights 28 Pa. Code 201.18 (e)(1)(6) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 9 of 16 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 01/18/2024 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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician extender, a physician assistant, wrote a progress note with each visit for one resident out of 14 residents reviewed (Resident CR 4). Findings include: A review of Resident CR 4's clinical record revealed a nurse's note dated January 9, 2024, at 12:32 PM, indicating that the in-house physician assistant was in the facility to see the resident. At the time of the visit, a new order was provided to send the resident home with 5 milligram (mg) oxycodone (an opioid narcotic pain medication) tablet. When reviewed during the survey ending January 18, 2024, there was no documented evidence in the resident's clinical record of the physician assistant's progress note for visit with the resident on the January 9, 2024, as noted in nurse's note on that same date. Interview with Employee 5, Physician Assistant (PA-C), via phone on January 18, 2024, at approximately 3:20 p.m., confirmed that the physician assistant did not write, sign and date a progress note at the time of the visit with the resident on January 9, 2024. Interview with the Director of Nursing (DON) on January 18, 2024, at approximately 3:20 p.m. verified that there was no Physician Assistant progress note for the visit on January 9, 2024, at the time of the survey on January 18, 2024. Refer F580 28 Pa. Code 211.2 (d)(8) Medical director 28 Pa. Code 211.5(f) Clinical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 10 of 16 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 01/18/2024 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 observation, a review of clinical records, select facility reports, information submitted by the facility and staff interviews, it was determined that the facility failed to fully develop and consistently implement 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 14 sampled residents (Residents 90 and Resident 86). Residents Affected - Some Findings include: Observation on the Arcadia Unit (dementia care unit) on January 18, 2024, at 11:15 AM revealed Resident 90 seated in a chair in the hall. The was visibly upset, and yelling at Resident 86 who was walking up and down the hallway and coming in close proximity to Resident 90. Employee 1 (LPN) was observed to speak with Resident 90 in a reassuring voice to calm the resident and redirected Resident 86 away from where Resident 90 was sitting. Interview with Employee 1 (LPN) at this time revealed that Resident 90 and Resident 86 do not get along and attempts are made to keep the two residents from within reach of each other. Employee 1 (LPN) confirmed that Resident 90 often sits in the hallway and that Resident 86 often walks up and down the hall. Employee 1 confirmed that both Residents 90 and 86 have dementia with behaviors and are not to be close to each other but it is difficult to always keep them out of each other's reach. Observation at this time also revealed that the scheduled 11:00 AM activity for the Arcadia Unit was not being offered as scheduled. A review of information submitted by the facility dated January 5, 2024, at 8:30 AM revealed that Resident 90 was seated in a wheelchair in the hall while Resident 86 was walking back and forth in the hall. Resident 90 was yelling out in the hall at Resident 86 and attempted to physically strike him. No contact was made but Resident 86 yelled back at Resident 90 in response and hit her left shoulder. The residents were immediately separated and 1:1 supervision provided until calm and pleasant. No injuries or complaints of pain were noted. The facility noted that Activity staff will determine a distracting activity for staff to initiate with Resident 90 when verbally aggressive. A review of information submitted by the facility dated January 5, 2024, at 4:45 PM (8 hours and 15 minutes after the incident which occurred at 8:40 AM on the same date) Employee 4 (LPN) witnessed Resident 90 walking down the hallway when Resident 86 walked out of his room, went over to Resident 90, and hit her on the side of her face unprovoked. Employee 4 (LPN) was at the medication cart and could not intervene in time to prevent the incident. Resident 86 was placed on 1:1 and a 302 (mandated request to receive inpatient psychiatric treatment) was initiated for Resident 86 and he was admitted to the hospital for evaluation and treatment for his escalation in behavior. Review of Resident 90's clinical record revealed the resident has a diagnosis of dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety, and depression. A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 21, 2023, revealed that the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 11 of 16 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 01/18/2024 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 was severely cognitively impaired with a BIMS score of 6 (the Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired). A review of Resident 90's care plan, initially dated June 17, 2023, identified a focus concern that the resident requires prompting for meeting emotional, intellectual, physical, and social needs due to cognitive deficits and goals to demonstrate comfort, acceptance, or enjoyment of activities as evidenced by activity enjoyment and maintain involvement in cognitive stimulation and social activities as desired. Planned interventions were to provide a program of activities that are of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility. A review of Resident 90's care plan identified a focus concern dated October 16, 2023, that the resident has the potential to be the recipient of aggression from another resident and a goal to be free from episodes of aggression from others. Planned interventions were to that during activity involvement keep resident out of direct reach from aggressive residents, monitor for interactions with aggressive residents, redirect as needed, monitor whereabouts of resident, and provide direct supervision to agitated or aggressive residents. Resident 90's care plan identified a focus concern dated December 28, 2023, and revised January 9, 2024, that the resident can be physically aggressive related to anger, dementia, and depression and a goal to demonstrate effective coping skills and not harm self or others. Planned interventions were to assess and anticipate resident's needs and provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage to seek out staff member when agitated. There was no evidence that the facility had revised and implemented an individualized person-centered plans to address, modify, and manage Resident 90's dementia-related behaviors based on the resident's past interactions with Resident 86. Further review of Resident 90's dementia related care plans revealed no documented evidence that a distracting activity for staff to initiate with Resident 90 when verbally aggressive was added to the resident's dementia care plan following the incident on January 5, 2024, at 8:40 AM. Review of Resident 86's clinical record revealed the resident had diagnoses which included Alzheimer's disease and psychotic disorder (mental disorder characterized by a disconnection from reality). A quarterly Minimum Data Set assessment dated [DATE], revealed that the resident was severely cognitively impaired, his primary language was Spanish, needs an interpreter to communicate with doctor or healthcare staff, and had behaviors which included physical, verbal, rejection of care, and wandering. A review of Resident 86's care plan initially dated July 9, 2023, and revised September 14, 2023, identified a focus concern that the resident has a behavior problem related to physical aggression, verbal aggression, refusing care, throwing communication boards away, yelling at staff and other residents, and sexually inappropriate with staff and a goal to be redirected and translation to be provided when needed due to language barrier. Planned interventions were to anticipate and meet the resident's needs and provide opportunities for positive interactions, stop and talk with resident as passing by, non-pharmacological interventions of Latin music and television, intervene as necessary to protect rights and safety of others, and every 15 minute safety checks (initiated December 18, 2023), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 12 of 16 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 01/18/2024 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 encourage activity participation, and provide 1:1 attention until behavior passes. Level of Harm - Minimal harm or potential for actual harm Further review of Resident 86's clinical record revealed that the resident was readmitted to the facility on [DATE], following the resident's 302 admission to the hospital for escalated behaviors on January 5, 2023, related to the incident with Resident 90. Residents Affected - Some There was no evidence that the facility had revised and implemented an individualized person-centered plan to address, modify, and manage Resident 86's dementia-related behaviors based on his physical aggression and recent hospitalization for his escalation in behavior. The residents' care plans 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, 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 director of nursing (DON) on January 18, 2024, at 2:00 PM confirmed that the facility failed to fully develop and implement dementia-care plans for both Residents 90 and Resident 86 and provide care and services to treat the residents' dementia related behaviors, including diversional activities. The DON confirmed that Resident 86 and Resident 90 were to not be within reach of each other to limit altercations and this approach was not included on the resident's care plans. 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 13 of 16 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 01/18/2024 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on review of the facility's plan of correction from the survey of November 17, 2023, and the findings of the survey ending January 18, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to activities and dementia care and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies. Findings include: The facility's deficiencies and plan of correction for the survey ending November 17, 2023, revealed that the facility developed a plan of correction that included quality assurance monitoring systems to ensure that solutions were sustained. The results of the current survey ending January 18, 2024, revealed that an ongoing activities program for the Arcadia Unit (dementia care unit) was not being provided on the day of the survey and continued deficient practice was identified related to activities not being provided. In response to the deficiency cited under activities during the survey of November 17, 2023, the facility's plan of correction revealed that the plan included that the nursing home or designee will interview five residents weekly times 12 to ensure interests/needs are included on the calendar. Nursing home administrator or designee will audit five dementia unit activities weekly times 12 to ensure activities are provided as planned. Results will be tracked and trended through the QAPI process. This corrective active plan was to be in place by January 16, 2024. However, at the time of the revisit survey ending January 18, 2024, observation of the Arcadia Unit revealed that scheduled activities were not being provided. Review of the activities department schedule for the date of the survey revealed that an activities aide was not scheduled for the Arcadia Unit for the date of the survey. The facility's quality assurance monitoring plan failed to identify this ongoing deficient practice. The facility's quality assurance plan failed to identify continued quality deficiency and sustain solutions to the identified quality deficiency in activities. In response to the deficiency cited under dementia care during the survey of November 17, 2023, the facility's plan of correction revealed that the plan included the director of nursing or designee will audit dementia unit residents care plans to ensure person-centered interventions to manage dementia related behaviors are in place. The director of nursing or designee will educate nursing staff on person centered care planning and interventions to decrease dementia behaviors. Interdepartmental facility staff will be educated on interactions with dementia residents. The director of nursing or designee will complete random observation audits weekly times 12 to ensure compliance and understanding. Results will be tracked and trended through the QAPI process. The corrective action plan was to be in place by January 16, 2024. However, at the time of the revisit survey ending on January 18, 2024, observation and review of clinical records revealed that the facility failed to fully revise and implement individualized person-centered care plans to address dementia related behaviors and the potential for altercations between Resident 86 and Resident 90. The facility's quality assurance monitoring plan failed to identify this ongoing deficient practice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 14 of 16 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 01/18/2024 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 0867 The facility's quality assurance plan failed to identify continued deficiency and sustain solutions to the identified quality deficiency in dementia care. Level of Harm - Minimal harm or potential for actual harm Refer F679 and F744 Residents Affected - Some 28 Pa. Code 211.12(c) Nursing services 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 15 of 16 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 01/18/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, it was determined that the facility failed to ensure that necessary mechanical and electrical resident care equipment was maintained in a safe and functional operating condition on two of three nursing unit floors (Floor 1 and 2). Residents Affected - Few Findings include: An observation on January 18, 2024, at 11:05 AM in Resident room [ROOM NUMBER] revealed a cracked two-prong receptacle outlet panel on the wall opposite the resident bed. The crack extended 3 inches down the left side of the panel cover, and metal from the electrical box was visible. During an observation on January 18, 2024, at approximately 10:15 AM of the 3rd floor nursing unit revealed a cord to the nurse call bell system was frayed, exposing internal wires, in resident room [ROOM NUMBER] -B. A second observation, on January 18, 2024, at approximately 12:40 PM, in the presence of Employee 4, maintenance director, of the 3rd floor nursing unit confirmed that resident call bell cord wa frayed, exposing internal wires, in resident room [ROOM NUMBER] -B. A review of Resident CR4's clinical record revealed concerns with the lack of timely reweighing the resident to verify a significant weight gain as the resident was presenting with +1 pitting edema of the extremities. Interview with Employee 5, Physician Assistant (PA-C), via phone on January 18, 2024, at approximately 3:20 p.m., revealed that the PA-C stated that she was not aware of Resident CR 4's significant weight gain. She stated that she recalled hearing nursing staff's conversations questioning the proper functioning of scales (on the 3rd floor). During an interview on January 18, 2024, at approximately 11:05 AM with Employee 4, maintenance director, Employee 4 confirmed that approximately 1-2 weeks ago the scale used for weighing residents was not properly functioning on the 3rd floor resident unit. Employee 4, stated that the administrator informed him of nursing staff's current complaints of a malfunctioning scale on the 3rd floor nursing unit. The maintenance director provided an email, entitled 3rd Floor Scale, dated January 10, 2024, at 1:10 PM, which confirmed the communication between the maintenance director and the facility administrator regarding the scale. Employee 4 also provided a prior work order dated November 2023, indicating that the battery on the same scale was changed. An observation, on January 18, 2024, at approximately 12:50 PM, in the presence of Employee 4, maintenance director, of the 3rd floor nursing unit revealed a floor wheelchair scale platform which Employee 4 confirmed was the scale that had malfunctioned and needed a new battery November 2023 and malfunctioned again in early January 2024. During an interview on January 18, 2024, at approximately 3:00 PM, the Director of Nursing (DON) confirmed that it is the facility's responsibility to ensure that mechanical, electrical, and resident care equipment are consistently maintained in a safe operating condition. 28 Pa. Code 202.18 (e)(2.1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395344 If continuation sheet Page 16 of 16