Health inspection·November 1, 2024

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation and staff interview, it was determined the facility failed to ensure the Department of Health most recenbt survey results were readily accessible to residents and visitors for two out of the three nursing units (Nursing Units 2 and 3). Residents Affected - Some Findings Include: During a resident council interview on October 30, 2024, at 10:00 AM, alert and oriented residents in attendance indicated they did not know where the facility posted the Department of Health survey results. During an observation on November 1, 2024, at 9:00 AM in the Unit 2 Nursing Station, the Department of Health survey results binder was located on the nursing station shelf. A medication cart was blocking access to the survey results. A review of the survey results binder revealed the facility failed to post information on the most recent department of health survey from August 2024. An observation on November 1, 2024, at 9:10 AM in the Unit 3 Nursing Station revealed the Department of Health survey results were not posted or accessible to residents and visitors. Residents and visitors were not able to access the survey results without asking staff for assistance. During an interview on November 1, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure the most recent Department of Health survey results are posted in a manner that is readily accessible to residents, family members, and legal representatives of residents. 28 Pa. Code 201.14(a) Responsibility of licensee. Page 1 of 18 395344 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0623 Level of Harm - Potential for minimal harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility-initiated transfer notices, and staff interview, it was determined the facility failed to provide copies of written notices of facility-initiated hospital transfers of residents to a representative of the Office of the State Ombudsman for five out of five residents reviewed for facility-initiated transfers (Residents 9, 13, 29, 45, & 102). Findings include: Regulatory requirements indicate that before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to the resident and/or resident's representative and to a representative of the Office of the State Long-Term Care Ombudsman. A review of the clinical record revealed Resident 9 was transferred to a community hospital on March 2, 2024, and readmitted to the facility on [DATE]. A review of the clinical record revealed Resident 13 was transferred to a community hospital on June 28, 2024, and readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 45 was transferred to the hospital on July 25, 2024, and was readmitted to the facility on [DATE]. A review of the clinical record revealed Resident 29 was transferred to a community hospital on August 13, 2024, and readmitted to the facility on [DATE]. Resident 29 was also transferred to the hospital on September 16, 2024, and readmitted to the facility on [DATE]. A review of the clinical record revealed that Resident 102 was transferred to the hospital on September 12, 2024, and returned to the facility on September 17, 2024. Resident 102 was also transferred to the hospital on September 17, 2024, and returned to the facility on September 24, 2024. Although written notices were provided to the residents, resident representatives, and the local Ombudsman of the facility-initiated transfers, there was no documented evidence the facility sent copies of written notices of these facility-initiated transfers to the representative of the Office of the State Long-Term Care Ombudsman. An interview with the Nursing Home Administrator (NHA) on November 1, 2024, at approximately 11:00 AM failed to provide documented evidence that copies of the facility-initiated transfer notices were sent to a representative of the Office of the State Long-Term Care Ombudsman. The NHA further confirmed there was no evidence that copies were sent to a representative of the Office of the State Long-Term Care Ombudsman since October 1, 2020. 28 Pa. Code 201.14(a) Responsibility of licensee. 395344 Page 2 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews, it was determined that the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for a Preadmission Screening and Resident Review (PASRR) level II resident review for one out of 25 residents (Resident 114). Findings include: Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long-term care. The PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have serious mental illness before admission. This is called a PASRR Level I screen. Those individuals who test positive for PASRR Level I are then evaluated in-depth; this is called PASRR Level II. The results of this evaluation result in a determination of need, a determination of an appropriate setting, and a set of recommendations for services for the individual's plan of care. A review of the Pennsylvania Department of Human Services Office of Long-Term Living Bulletin titled Revised Pennsylvania Preadmission Screening Resident Review (PASRR) Level 1 Identification Form (MA 376), effective July 1, 2024, revealed if the individual has a change in condition that affects program office criteria as found on the PASRR Level I form, a PASRR Level II evaluation form will need to be completed. Nursing facilities will communicate the need to have a PASRR Level II form done by notifying the department's Office of Long-Term Living, Division of Nursing Facility Field Operations Team. A clinical record review revealed Resident 114 was admitted to the facility on [DATE], with a diagnosis including dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of the Pennsylvania Preadmission Screening Resident Review (PASRR) Identification Level I form, dated June 2, 2023, indicated Resident 114 does not have a mental health condition or suspected mental health condition other than dementia that may lead to a chronic disability (examples include schizophrenia, psychotic disorder, and personality disorder). The form indicated Resident 114 is a negative screen for serious mental illness; no further revaluation (Level II) is necessary. A psychiatric consultation note dated November 13, 2023, revealed an evaluation of Resident 114's mood, behaviors, and history indicated the resident's psychosis is not under control; her behaviors are severe and complicated, requiring an ongoing one staff to one resident (1:1) level of supervision. The consultation note indicated Resident 114 is receiving treatments for her schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). A care plan indicates Resident 114 has a mood problem related to schizophrenia initiated on March 1, 2024. 395344 Page 3 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A psychiatric consultation note dated September 25, 2024, revealed ongoing evaluation of Resident 114's mood and behavior. The note indicates Resident 114 has had a complicated stay in the facility, and after a very lengthy conversation with the resident's family and a review of her home behavior with a five-year lookback, the resident is noted to have a narcissistic personality and violent tendencies requiring a one-to-one level of supervision at the facility. The note also indicates Resident 114 is receiving treatments for schizophrenia. During an interview on October 30, 2024, at 1:00 PM, Employee 1, Director of Social Services, indicated that she had no documented evidence of reporting Resident 114's diagnoses of schizophrenia or narcissistic personality disorder to the state's mental health authority to determine if Resident 114 was appropriately placed in a nursing facility or required additional services to treat her mental health diagnoses. During an interview on November 1, 2024, at approximately 11:00 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition are referred for a Preadmission Screening and Resident Review (PASRR) level II. 28 Pa. Code 201.14(a) Responsibility of licensee. 395344 Page 4 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, calendar of activities programming, and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs, interests, preferences, and functional and cognitive abilities of two of the 25 residents reviewed (Residents 31, 95) and experiences expressed by residents during a group interview (Residents 9, 84, 97, & 104). Residents Affected - Some Findings include: During a resident group interview on October 30, 2024, at 10:00 AM, alert and oriented residents expressed dissatisfaction with the facility's activity offerings, particularly noting the lack of options in the evenings. Resident 9 reported that Bible study appears to be the only evening activity, and he expressed his interest in more engaging options, such as games, stating he would be willing to participate in almost any evening activity offered. Resident 84 expressed similar concerns, stating that she enjoys bingo and would like to see it offered more frequently, especially in the evenings. She also emphasized a desire for a broader variety of activities. Resident 97 shared that, aside from bingo, she finds the current activity schedule unsatisfactory and would like to see more arts and crafts activities as well as outdoor options. Similarly, Resident 104 noted that although bingo is available a few times a week, she is dissatisfied with the limited activity variety and would like to see more evening activities scheduled. A review of the October 2024 activity calendar revealed evening activities were offered on Tuesdays and Thursdays at 6:30 PM. A review of the upcoming activity calendar revealed that evening activities would be reduced to three days out of 30 in the month of November. Review of the clinical record revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses that included diabetes and paraplegia (paralysis of the legs and lower body). An annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated July 2, 2024, indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 (a score of 13-15, indicates cognitively intact), activity preferences very important included music, animals, keeping up with the news, and going out for fresh air, and activity preferences somewhat important included doing things with a group of people. Interview with Resident 31 on October 30, 2024, at 10:00 AM revealed the resident does mostly prefer independent activities in his room, such as watching television, but that he does like to be made aware of activities being offered in the facility. Resident 31 also stated that he enjoys Word Find Puzzle books but does not currently have any to complete. Observation at this time revealed the current activity calendar on the resident's bulletin board was for September 2024. Resident 31 stated that he does not recall any recent visits from the activities department. Resident 31 stated that he did not have a current activity calendar. A review of Resident 31's current care plan, initially dated August 31, 2022, indicated the resident prefers independent/self-driven activities, likes watching the news and current events, being outdoors, playing cards, and cooking. Interventions included for staff to invite, make arrangements, 395344 Page 5 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some offer materials, or provide assistance to facilitate participation in interests and for staff to meet with the resident to see if enjoyment is gained from activities or a self-directed routine. Further review of the clinical record revealed no documented evidence of the resident's participation in activities. There was no documented evidence that room visits were being completed to ensure the resident was being provided with an ongoing program of activities to meet his needs. Review of the clinical record revealed that Resident 95 was admitted to the facility on [DATE], with diagnoses that included intellectual disability (below average intelligence and set of life skills present before age [AGE]) and cerebral palsy (congenital disorder or movement, muscle tone, or posture). An admission Minimum Data Set assessment dated [DATE], indicated the resident was severely cognitively impaired, and activity preferences included being around animals and pets and going outside for fresh air. Further review of the clinical record revealed no evidence that an activity assessment and care plan specific to meeting the resident's activity needs were completed. There was no documented evidence of Resident 95's participation in activities or visits being provided to ensure the resident was being provided with an ongoing program of activities to meet her needs. Interview with the Nursing Home Administrator (NHA) on November 1, 2024, at 10:30 AM failed to provide documented evidence that Resident 95 and Resident 31 were being provided an ongoing program of activities designed to meet their interests and support their physical, mental, and psychosocial well-being. The NHA confirmed that Residents 9, 84, 97, and 104 should have access to group, individual, and independent activities developed based on their interests and designed to support their physical, mental, and psychosocial well-being. 28 Pa. Code 201.18 (e)(1)(6) Management. 28 Pa. Code 201.29 (a) Resident rights 395344 Page 6 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select investigative reports, and staff interview, it was determined the facility failed to provide care necessary to prevent complications with a gastric feeding tube for one resident out of four sampled (Resident 95). Findings include: Review of Resident 95's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses, which included dysphagia (difficulty swallowing) and a gastrostomy tube. (a tube inserted into his stomach). The resident had a physician order for Jevity 1.5 Enteral Liquid (liquid feeding formula) 68 milliliters per hour (ml/hr) via PEG-Tube (tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), and a water flush of 50 ml every 1 hour during the pump infusion. Review of the resident's care plan initially dated August 31, 2024, and revised September 4, 2024, indicated the resident has a potential for impairment to skin integrity. Interventions to help the resident maintain intact skin included an abdominal binder (wide compression belt that encircles the abdomen to prevent pulling out the tube) with frequent skin checks due to resident's tactile response PEG placement. Review of a facility investigation report dated October 4, 2024, at 11:50 PM indicated that nurse aides performing care found resident's g-tube to be dislodged with the balloon intact (water-filled balloon that holds the tube in place in the stomach). The resident was assessed for trauma to the insertion site with none noted. A physician's order was received to send the resident to the hospital for reinsertion of the peg tube. Further review of the facility investigation report revealed the resident's abdominal binder was found on the bedside table. The investigation failed to address why the resident was not wearing the abdominal binder prior to the incident. Interview with the director of nursing (DON) on November 1, 2024, at approximately 11:30 AM confirmed the above event requiring Resident 95's transfer to the hospital. The DON failed to provide documented evidence that the facility effectively implemented the resident's abdominal binder to prevent dislodgement of the resident's PEG-tube to the extent possible. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. 395344 Page 7 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 staff interview, it was determined the facility failed to ensure the resident's drug regimen was free of unnecessary antibiotic medication for one out of 25 residents sampled (Resident 88). Residents Affected - Few Findings included: A clinical record review revealed Resident 88 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing) after a stroke, hypertension, and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A community hospital emergency department document dated October 23, 2024, indicated that Resident 88 was evaluated in the emergency room after a fall out of bed at the facility with no evidence of acute trauma.The resident's laboratory values were at baseline. A slight urinary tract infection was noted and the resident was started on antibiotics. Further review of the hospital after visit summary revealed that a urinary culture (a urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) was pending and that if the culture ended up being negative the antibiotics would be discontinued. The emergency room discharged Resident 88 back to the facility on October 23, 2024, with new orders for Bactrim DS (antibiotic) one tablet two times a day for 7 days for urinary tract infection, with one dose administered while the resident was in the emergency room. Review of documentation dated October 23, 2024, at 2:29 p.m., indicated the resident's attending physician approved the orders from the hospital. Review of the resident's clinical record failed to provide evidence of the urine culture results to confirm the necessary antibiotic treatment for the possible urinary tract infection. Interview with the facility's Infection Preventionist on November 1, 2024, at approximately 9:45 a.m. confirmed the urinary culture and/or sensitivity was not available on the resident's clinical record. The Infection Preventionist further stated that according to conversation with the hospital, the urine culture and sensitivity report (a urine culture is a method to grow and identify bacteria that may be in the urine. The sensitivity test helps select the best medicine to treat the infection) was not completed as indicated in the resident's emergency room record. There was no documented evidence the resident had experienced any symptoms of a urinary tract infection, such as fever, chills, mental changes, confusion, fatigue, nausea, vomiting, pressure in the lower part of the pelvis, or an increase in urination. Review of Resident 88's Medication Administration Record dated October 2024 revealed the resident received 14 doses of antibiotic therapy for a probable urinary tract infection from October 24, 2024, through October 30, 2024. During an interview on November 1, 2024, at approximately 12:30 p.m., the Director of Nursing confirmed the administration of Bactrim was not clinically justified for use due to lack of evidence of a 395344 Page 8 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0757 UTI. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.2 (d)(3) Medical Director 28 Pa. Code 211.9 (k) Pharmacy Services Residents Affected - Few 28 Pa. Code 211.12 (d)(3) Nursing Services 395344 Page 9 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of select facility policy, and resident and staff interview, it was determined the facility failed to provide dental services for two residents out of 25 residents sampled (Residents 92 and 31). Residents Affected - Some Findings include: According to federal guidelines under §483.55 Dental Services, the facility must assist residents in obtaining routine and 24-hour emergency dental care. Under these guidelines, emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate; broken or otherwise damaged teeth; or any other problem of the oral cavity that required immediate attention by a dentist. For Medicaid residents, the facility must provide all emergency dental services and those routine dental services to the extent covered under the Medicaid state plan. The facility must inform the resident of the deduction for the incurred medical expense available under the Medicaid State Plan and must assist the resident in applying for the deduction. If any resident is unable to pay for dental services, the facility should attempt to find alternative funding sources or delivery systems so that the resident may receive the services needed to meet their dental needs and maintain his/her highest practicable level of well-being. This can include finding other providers of dental services, such as a dental school or the provision of dental hygiene services on site at a facility. Review of the facility Dental Services Policy last reviewed September 26, 2024, indicated that if a resident loses his/her dentures and it was determined the loss or damage of the denture is the facility responsibility the following will occur: the facility may not charge a resident for the loss or damage of dentures when determined to be the facility's responsibility in accordance with the facility grievance policy. A clinical record review revealed Resident 92 was admitted to the facility on [DATE], with medical diagnoses that include multiple sclerosis (a disease where the immune system mistakenly attacks the protective covering around nerves in the brain and spinal cord). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 21, 2024 revealed that Resident 92 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During an interview on October 20, 2024, at 10:30 AM, Resident 92 indicated she had a dental appointment months ago. She explained the dentist recommended dentures, but the facility has not assisted her with the process. Resident 92 expressed frustration due to the lack of assistance. A clinical record review revealed a dental consultation sheet dated June 26, 2024, with recommendations for Resident 92 to have full upper dentures. 395344 Page 10 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0791 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A dental consultation treatment plan recommendation dated June 26, 2024, indicating full dentures are needed to fill the void of all missing teeth on the jaw so the resident can eat and not lose weight. The recommendation indicated the facility contact a local oral surgeon to schedule to extract mandibular teeth as needed if painful. A progress note dated August 24, 2024, at 1:50 PM indicated the resident was seen by dental services and is waiting for full upper dentures. The note indicated the physician and resident representative were made aware. Following questions asked during the survey, the facility provided documentation indicating Resident 92 now has approval to have impressions for full upper dentures as of October 31, 2024. During an interview on November 1, 2024, at approximately 11:00 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure residents receive assistance in obtaining routine and 24-hour emergency dental care. The NHA was unable to provide documented evidence that Resident 92 was assisted with follow-up recommendations made during a dental consultation in June 2024, until inquiries were made during the week of the survey. A clinical record review revealed Resident 31 was admitted to the facility on [DATE], with diagnoses that include paraplegia (paralysis of the legs and lower body). A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 1, 2024 revealed that Resident 31 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). During interview with Resident 31 on October 30, 2024, at 10:00 AM the resident stated the bottom denture he received in the past was missing. Resident 31 noted that staff were aware his lower denture was missing. Resident 31 could not remember when his lower denture went missing but that it had been a while. Review of the clinical record revealed a dental visit dated April 2, 2024, which revealed that a full lower denture was provided to the resident. Review of Resident 31's care plan initially dated March 11, 2024, indicated the resident has an oral/dental health problem due to no natural teeth. An intervention dated May 8, 2024, noted the resident is non-compliant with proper care of dentures, leaves them on food trays and wrapped in napkins despite education. Further review of the clinical record revealed no documented evidence the facility identified that Resident 31's full lower denture was missing. There was no documented evidence the facility investigated as per the facility policy to determine if the facility would be responsible to pay for the cost to replace Resident 31's full lower denture. Interview with the administrator on November 1, 2024, at approximately 11:30 AM failed to provide documented evidence the facility investigated to determine what had happened to Resident 31's full 395344 Page 11 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0791 lower denture and if the facility would be responsible for replacement. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.15 Dental services. Residents Affected - Some 395344 Page 12 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of scheduled facility mealtimes and select facility policy, and resident and staff interviews, it was determined the facility failed to consistently provide snacks as desired by residents, including experiences reported by residents during a group interview (Residents 9, 50, 84, 85, 92, 97, 104, & 107). Findings include: A review of facility policy titled H.S.(hour of sleep) Snack Policy, last reviewed by the facility on September 26, 2024, revealed it is the facility's policy that all residents (unless NPO-nothing by mouth) will be offered an appropriately textured bedtime snack. The policy indicates if the meal span between the evening meal and breakfast the next day exceeds 14 hours, then a nourishing snack will be offered. The nourishing snack that will be offered will include food items from at least two food groups, one of which provides protein. A review of the facility's scheduled mealtimes revealed the time between dinner and breakfast the next day exceeds 14 hours. A clinical record review revealed Resident 9 was admitted to the facility on [DATE]. An annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 6, 2024, revealed Resident 9 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). A clinical record review revealed Resident 97 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE], revealed Resident 97 is cognitively intact with a BIMS score of 14. A clinical record review revealed Resident 50 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE], revealed Resident 50 is cognitively intact with a BIMS score of 15. A clinical record review revealed Resident 107 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE], revealed Resident 107 is cognitively intact with a BIMS score of 15. A clinical record review revealed Resident 84 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE], revealed Resident 84 is cognitively intact with a BIMS score of 14. A clinical record review revealed Resident 92 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE], revealed Resident 92 is cognitively intact with a BIMS score of 15. A clinical record review revealed Resident 104 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE], revealed Resident 104 is cognitively intact with a BIMS score of 15. A clinical record review revealed Resident 85 was admitted to the facility on [DATE]. A significant change in status MDS assessment dated [DATE], revealed Resident 85 is cognitively intact with a BIMS score of 15. 395344 Page 13 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0809 Level of Harm - Minimal harm or potential for actual harm During a resident group interview on October 30, 2024, at 10:00 AM, eight residents in attendance stated that they are not consistently offered a nourishing evening snack (Residents 9, 50, 84, 85, 92, 97, 104, & 107). The residents in attendance indicated the facility runs out of snacks and explained that staff do not always distribute the snacks to residents. The residents in attendance expressed frustration about not having snacks. Residents Affected - Some During an interview on November 1, 2024, at approximately 11:00 AM, the Nursing Home Administrator (NHA) was unable to explain why residents are reporting the facility is not offering nutritious snacks as desired. The NHA confirmed it is the facility's policy to offer and serve residents a nourishing snack in accordance with their needs, preferences, and requests at bedtime on a daily basis. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 395344 Page 14 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, it was determined the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in three of four resident pantries (First Floor, Second Floor, and Third Floor). Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean, and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness, according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food). During the initial tour of the kitchen with the facility's registered dietitian on October 29, 2024, at 9:30 AM revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness: There were 40 four-ounce thawed nutritional shakes without a thaw or discard date on the shelf in the refrigerator. The manufacturer instructions noted the shakes were to be consumed within 14 days of thawing. There were five sheet trays in the refrigerator containing 4-ounce servings of canned fruit cocktail which were not covered and dated. There were six cases of assorted food products being stored directly on the floor in the dry storage room. Interview with the registered dietitian at this time confirmed that food was to be stored in a sanitary manner. Observation of the Third-Floor resident pantry refrigerator on November 1, 2024, at 9:50 AM revealed two four-ounce thawed nutritional shakes without a thaw or discard date. Observation of the Second-Floor resident pantry refrigerator on November 1, 2024, at 10:00 AM revealed one four-ounce thawed nutritional shakes without a thaw or discard date. Observation of the First-Floor resident pantry on November 1, 2024, at 10:15 AM revealed the end of the condensation hose (hose connected to the ice machine and collects water that empties from the ice machine) leading from the ice machine to the floor drain had a heavy buildup of a pink-colored slime on the end of the hose. Interview with the nursing home administrator on November 1, 2024, at 11:00 AM confirmed that sanitary practices for food and ice storage should be maintained in the resident pantries. 395344 Page 15 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0812 28 Pa. Code 201.18 (e)(2.1) Management. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395344 Page 16 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0926 Have policies on smoking. 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 facility policy, observation, and resident and staff interview, it was determined the facility failed to implement established facility policy procedures for smoking, smoking areas, and smoking safety as evidenced by one out of 25 sampled residents (Resident 100). Residents Affected - Some Findings include: Review of the facility policy titled Non-Smoking Facility Policy, initially dated December 4, 2023, and last reviewed by the facility, September 26,2024, indicated it is the facility to provide a safe environment for 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 resident's 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 Tuesday, October 29,2024, at approximately 10:15 AM, the Director of Nursing (DON), and the Nursing Home Administrator (NHA) stated the facility is a non-smoking facility. A review of Resident 100's clinical record revealed the resident was admitted to the facility on [DATE], with a diagnosis to include abnormal posture (rigid body movements or abnormal positions of the body) and muscle wasting and atrophy (loss or thinning of muscle). A review of Resident 100's clinical record revealed that Resident 100 was alert and oriented. A review of Resident 100's care plan dated April 26, 2024, indicated the resident smokes cigarettes. The care plan did not identify the location of the resident's smoking materials, include specific times to smoke, or restriction of times, and or any equipment the resident required for safe smoking. A review of Resident 100's clinical record revealed the resident was noncompliant with the facility's smoking policy. Further review of the clinical record revealed a quarterly smoking evaluation dated February 8, 2024, indicated the resident does smoke, and has a dexterity issues (loss or underdevelopment of fine motor skills). An observation made on Wednesday, October 30,2024, at 1:22 P.M. revealed Resident 100 signed out for LOA (leave of absence) on a clip board posted at the nurse's station, removed a crossbody bag containing his cigarettes and lighter from the nurse's station and placed it over his head and across his body. It was then observed Resident 100 ambulated with the assistance of a rollator walker to the end of the facility entrance. During this observation, no staff were present when the resident signed out or when he retrieved the crossbody bag. Resident 100 was then observed crossing the street of 395344 Page 17 of 18 395344 11/01/2024 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility property, where he was witnessed removing a cigarette and a lighter from the crossbody bag and then lighting a cigarette at 1:25 P.M. During this observation, there were no smoking receptacles present in area for the resident to safely discard the cigarettes. Documentation provided by the facility during the survey on October 31,2024 at 9:30 A. M. revealed that Resident 100 did not have a current quarterly smoking assessment. Interview with the DON at this time confirmed the last smoking assessment was completed on February 8, 2024. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on October 31, 2024, at approximately 1:30 P.M., the facility was aware of Resident 100 was keeping his crossbody bag containing cigarettes and a lighter at the nurses station. The NHA and DON confirmed they were aware Resident 100 was smoking at the end of the facility front entrance. The NHA failed to provide documented evidence the Non-Smoking Facility Policy was implemented as established by the facility. 28 Pa. Code 201.18 (b)(1)(e)(1)(2.1) Management 28 Pa. Code 209.3 (a)(c) Smoking. 395344 Page 18 of 18