Health inspection·August 6, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and orderly environment two of three nursing units (A and B unit, C unit; Residents 3, 4, 5, 6, 7, and 8). Findings include: Observation of Resident 3's room on August 6, 2024, at 8:18 AM revealed a two light bulb fixture recessed into the ceiling of the bathroom, which also served as the exhaust fan. The unit contained a thick coating of dust covering the interior portion of the unit visible when looking up at the light. A rusty metal washer was lying on the floor to the right sink side of the toilet base, and an additional washer was observed on the base of the toilet next to it. A large pile of black and brown debris was scattered on the base of the toilet covering where the washers were located. An observation of Resident 6's bathroom on August 6, 2024, at 8:27 AM revealed peeling wallpaper along the walls where the wallpaper met the cove base. An observation of Resident 5's room on August 6, 2024, at 8:38 AM revealed dried food and debris collected around the metal portion of the bed frame on the floor at the base of the bed. The bathroom floor tile contained discolored stains and debris. The caulking surrounding the base of the toilet was blackened. Several holes were observed in the wall appearing to be where prior items were hung on the wall. A larger hole 1 inch x 2 inch was observed on the wall beside the toilet. Dirt/debris buildup was observed along the walls and corners where the cove base meets the flooring. Cobwebs were observed over the ceiling light in the bathroom covering the light and extending to the ceiling tiles. The exhaust fan was making a screeching noise. Dust buildup was observed in the visible interior portion of the recessed bathroom light. A sink located directly outside Resident 5's bathroom was observed with black and brown dried debris surrounding the drain area of the sink extending throughout the sink basin, large pieces of dried debris were observed on the sink drain. Neither hot nor cold water knobs turned on any water to the sink. An observation of Resident 4's room on August 6, 2024, at 9:19 AM revealed a sheer window curtain inside of the thicker drape covering the window. The sheer curtain contained a dried brown/orange water mark 18 inches up the curtain at levels across the curtain. A large vertical tear in the curtain greater than 12 inches was also observed. A wallpaper border above the resident's bed was peeling off the wall and hanging at the border seam. The wallpaper behind the resident's bed was peeling away from the wall. An observation of Resident 7's room located on the lowest level of the facility (which has no roof (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395359 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 395359 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jersey Shore Skilled Nursing and Rehabilitation Ce 1008 Thompson Street Jersey Shore, PA 17740 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)