Health inspection·December 11, 2025

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and documentation provided by the facility, observations, and staff interviews, it was determined that the facility failed to develop, revise, and consistently implement an individualized, person-centered plan of care to identify, prevent, and manage dementia-related behaviors for one resident out of eight residents sampled (Resident 1). Findings include: A review of the clinical record revealed Resident 1 was admitted on [DATE], with diagnoses that included cerebral infarct (a stroke caused by interrupted blood flow to the brain) and alcohol-induced persisting dementia (long-term cognitive impairment resulting from chronic alcohol use causing permanent brain damage). A review of an quarterly Minimum Data Set assessment (MDS, a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 25, 2025, revealed Resident 1 was moderately cognitively impaired with a BIMS score of 9 (Brief Interview for Mental Status, a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates moderately, cognitively impaired). A review of the resident's care plan revealed a problem addressing behavioral symptoms was initiated on October 2, 2025, identifying behaviors that included cursing at staff, resisting care, noncompliance with transfers, statements wishing she was dead, and wandering into other residents' rooms. Interventions listed included placing a name sign outside the resident's room, identifying broad behavioral triggers, one-to-one conversation, offering cooling-off periods or naps, administering medications, and anticipating needs. The care plan lacked specific, individualized, and actionable interventions tailored to the resident's repeated aggressive behaviors, unsafe wandering, and escalation toward residents, staff, and visitors. Further review of the resident's Activities of Daily Living (ADL) care plan initiated June 3, 2025, indicated the resident required assistance of one staff member for ambulation with a rolling walker. Despite this, nursing documentation throughout September and October 2025 repeatedly reflected the resident ambulating independently throughout the unit during episodes of agitation and behavioral escalation, without evidence the care plan was revised to address safety risks or supervision needs. A review of nursing documentation revealed that beginning in September 2025, Resident 1 demonstrated a pattern of escalating dementia-related behaviors, including repeated verbal aggression, inability to be redirected, wandering into other residents' rooms, and threatening or unsafe actions:September 4, 2025, at 7:21 AM:Nursing documentation reflected that during the prior 11:00 PM to 7:00 AM shift, Resident 1 was observed going through her roommate's personal belongings. Staff redirected the resident multiple times during the shift, after which the resident became angry and yelled at staff. Later the same day, the Social Services Director met with Resident 1 to discuss personal space. During that interaction, Resident 1 stated she was missing a box and reported she was only searching for it. The resident denied yelling at staff.September 13, 2025, at 4:02 PM:Resident 1 was observed yelling at her roommate and stating, Get this Residents Affected - Few Page 1 of 3 395344 395344 12/11/2025 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few thing out of here. Staff removed Resident 1 from the room and escorted her to the dining room to de-escalate the situation. Resident 1 requested a room change due to ongoing conflict with her roommate. The responsible party was notified and agreed to the room change. Resident 1's was changed. September 21, 2025, at 6:37 AM:Nursing documentation indicated that during the 11:00 PM to 7:00 AM shift, Resident 1 exited her room into the hallway multiple times yelling for staff assistance. When staff approached, the resident became verbally combative. Documentation reflected the resident was disruptive to other residents who were sleeping on the unit and was unable to be redirected. September 26, 2025, at 12:31 PM:Resident 1 was documented as ambulating independently out of her room while yelling for help and being verbally abusive toward staff and other residents. The resident's verbal abuse toward staff was again documented during the month of October 2025.October 7, 2025, at 1:43 PM:During the lunch meal, Resident 1 stated, If I had a gun, I would kill myself, after expressing dissatisfaction with the food on her lunch tray. Nursing staff remained with the resident in her room for a documented cooling-off period. Documentation indicated the resident had previously been seen by contracted psychiatric services. The note identified the resident as her own responsible party; however, the clinical record reflected the resident's niece was the responsible party. The responsible party was not contacted or notified of the incident. Interventions documented at the time included encouraging the resident to use deep breathing techniques to calm herself and to talk with staff when issues were bothering her. October 11, 2025, at 4:05 AM:Resident 1 was observed on her roommate's side of the room repeatedly shutting the window after the roommate asked several times for her to stop. Later during the same shift, Resident 1 was documented as verbally abusive toward nursing staff. Documentation reflected the resident was ambulating independently in her room and was not calling staff for assistance. October 26, 2025, at 10:57 AM:Nursing documentation indicated Resident 1 was found in another resident's room stating the room belonged to her and that others needed to leave. The resident was redirected back to her assigned room. The documented intervention was to move Resident 1 to a different room with a new roommate. October 27, 2025, at 1:07 PM:Documentation from the Social Services Director reflected receipt of a telephone call from Resident 2's daughter, who reported that Resident 1 had been verbally aggressive toward Resident 2 and family members and often became agitated when visitors were present in the room. The Social Services Director counseled Resident 1 regarding her behavior and offered support. October 30, 2025, at 3:30 PM:Nursing documentation reflected that Resident 1 was present in another resident's assigned room while that resident's family member was visiting. Resident 1 was observed yelling at the family member and stated, You are the devil. Documentation further reflected that Resident 1 attempted to throw her walker toward the family member. October 30, 2025, at approximately 3:30 PM:Resident 1 was escorted by staff out of the other resident's room and returned to her assigned room. The documented intervention at that time was for nursing staff to provide comfort to Resident 1. October 30, 2025, at 10:50 PM:A resident/family grievance submitted by Resident 2's family member (daughter) reported that Resident 1, identified as the roommate, had been verbally aggressive toward her. The family member requested that her mother be assigned to a different roommate due to ongoing behavioral concerns. October 30, 2025 (no time documented):A witness statement from Employee 1 (nursing assistant) indicated that Resident 1 had a room change earlier in the day at approximately 1:00 PM. While the room transfer process was occurring, Resident 2's daughter arrived on the unit to visit her mother. The family member ran into the hallway yelling for help. Upon entering the resident room, Employee 1 observed Resident 1 exiting the room independently, cursing and yelling about the family member. Employee 1 escorted Resident 1 back to her assigned room.October 30, 2025 (no time documented):A witness statement from Employee 2 (nursing 395344 Page 2 of 3 395344 12/11/2025 Edenbrook of Greenwood Hill 420 Pulaski Drive Pottsville, PA 17901

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assistant) indicated that Resident 1 had a room change earlier in the day. While seated at the nurses' station, Employee 2 heard yelling and ran down the hallway. Employee 2 observed Resident 1 exiting another resident's room and arguing with Resident 2's daughter. The family member reported that Resident 1 threw her walker toward her.Despite this sustained pattern of behaviors, the facility relied primarily on room changes, redirection, and brief calming measures, without evidence of meaningful revision of the resident's care plan to include individualized dementia-specific strategies, environmental modifications, staffing approaches, or structured interventions designed to prevent recurrence.The facility was unable to provide a Dementia Care Program or policy at the time of the survey. While staff education materials addressing dementia care and person-centered interventions were provided, the facility failed to translate this education into individualized care planning and consistent implementation for Resident 1.During an interview with the Nursing Home Administrator and Director of Nursing on December 11, 2025, at 1:00 PM, both confirmed the facility failed to ensure Resident 1's care plan was revised and implemented to address her documented dementia-related aggressive and wandering behaviors using individualized, person-centered interventions consistent with dementia care standards. 28 Pa. Code 201.18 (a)(1) Management. 28 Pa. Code 211.12 (d)(1)(5) Nursing services 28 Pa. Code 211.10 (a) Resident care policies 395344 Page 3 of 3