Health inspection·August 29, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interview, it was determined the facility failed to ensure that a resident who is dependent on staff for toileting, toileting hygiene, and mobility in bed, receives the appropriate treatment and services to meet the professional standards of care to the extent possible for one of six residents reviewed (Resident 4). Residents Affected - Few Findings include: In an interview with Resident 4 on August 29, 2024, at 10:24 AM the resident was observed lying in bed stating she was waiting to go get a shower. Resident 4 stated, It takes two people to change me and sometimes they wait until my shower in the morning to change me, but I have been lying here wet, and I am soggy. Resident 4 indicated she last had her brief changed at 4:00 AM. A slight urine odor was present near the resident and as the resident had her covers pulled back, with her brief exposed, the brief appeared wet and full. Resident 4 stated she has had a diaper rash for two months. Resident 4 also indicated she was not provided her dentures for breakfast and did eat the oatmeal and French toast that was served because they were soft enough. Resident 4 indicated her dentures were kept in a black box on her bedside stand. No dentures were observed in the resident's mouth. A black denture container was observed on the resident's bedside stand to the right of the resident's head of bed beyond the resident's reach. Clinical record review for Resident 4 revealed a quarterly MDS (minimum data set, an assessment completed at specific intervals of time to determine resident care needs) dated August 22, 2024, in which facility staff assessed the resident as being dependent on staff for bed mobility, toileting hygiene, and that the resident was frequently incontinent of urine. Review of Resident 4's [NAME] (a guide to resident care needs) revealed the resident transfers with a full body mechanical lift and was to have an individual toileting plan of scheduled toileting of AM/PM care, before breakfast and lunch, after supper, HS (evening), and second rounds on 11-7 as needed. A review of a Urinary Incontinence assessment completed for Resident 4 upon the resident's admission to the facility dated July 28, 2023, indicated staff assessed the resident's type of incontinence as, Functional, can't get to the toilet in time due to physical disability, external obstacles, or problems thinking or communicating. In an interview with Employee 1 and Employee 2, nurse aides assigned to Resident 4's hall, on August 29, 2024, at 10:30 AM, Employee 1 stated she had reported to work at 7:00 AM to Resident 4's hall, (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 08/29/2024 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)