Health inspection·May 16, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on clinical record review and staff interview, it was determined that the facility failed to implement a resident's right to refuse medications for one of one resident reviewed (Resident 69). Residents Affected - Few Findings include: Clinical record review for Resident 69 revealed that the facility admitted her on October 8, 2024, with a diagnosis of Cerebral Palsy (a disorder that affects muscle tone, movement, and posture due to abnormal brain development before birth). A nursing progress note for Resident 69 dated March 31, 2025, at 1:16 PM indicated that she would not take her evening medications and clamped her mouth shut when offered them. The note indicated that the medications were then given to her through her G-Tube (Gastrostomy tube, a small flexible tube surgically inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications). Further clinical record review revealed that Resident 69's medications were ordered to be given by mouth and there was no order to administer them through her G-Tube. Interview with the Nursing Home Administrator on May 15, 2025, at 10:15 AM revealed that the nurse should not have administered Resident 69's medications through the G-Tube after she refused them and clamped her mouth shut. The facility failed to honor Resident 69's right to refuse her medications. 28 Pa. Code 201.29(a) Resident rights 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 2 of 25 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 05/16/2025 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)

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from medications potentially classified as a chemical restraint for one of six residents reviewed (Resident 46). Findings include: Clinical record review for Resident 46 revealed an order dated February 11, 2025, for Lorazepam (a medication used to treat anxiety) oral tablet 0.5 mg by mouth every six hours as needed for anxiety and agitation. Further clinical record review revealed that Resident 46's order for Lorazepam did not have a 14 day stop date and there was no physician's progress note that provided a rationale for the medication extending past 14 days. Review of Resident 46's medication administration record revealed that she utilized the as needed Lorazepam two times in April 2025, and seven times from May 1-14, 2025. Interview with the Nursing Home Administrator on May 15, 2025, at 10:31 AM confirmed the above noted findings related to Resident 46's Lorazepam. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 3 of 25 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 05/16/2025 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)

F 0628 Level of Harm - Potential for minimal harm Residents Affected - Some Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on clinical record review and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman upon transfer to the hospital for five of seven residents reviewed for hospitalizations (Residents 37, 42, 45, 47, and 79). Findings include: Review of Resident 45's clinical record revealed that the facility transferred him to the hospital on April 5, 2025. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 45's transfer to the hospital on April 5, 2025. Interview with the Administrator on May 15, 2025, at 10:20 AM confirmed the above findings for Resident 45. Review of Resident 47's clinical record revealed that the facility transferred him to the hospital on April 13, 2025. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 47's transfer to the hospital on April 13, 2025. Review of Resident 79's clinical record revealed that the facility transferred him to the hospital on April 21, 2025. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 79's transfer to the hospital on April 21, 2025. Interview with the Nursing Home Administrator on May 15, 2025, at 10:15 AM revealed that the ombudsman is to be notified of all the transfers that occur within the month, at the end of every month. She stated that she could not find evidence that this was done since August of 2024. Clinical record review for Resident 37 revealed the resident was transferred to the hospital on April 17, and again on April 24, 2025. There was no documented evidence as of May 15, 2025, that the facility notified the Office of the State Long-Term Care Ombudsman regarding Resident 37's transfers to the hospital as noted. Interview with the Nursing Home Administrator on May 15, 2025, at 10:00 AM confirmed the above findings for Resident 37. Clinical record review for Resident 42 revealed that they were transferred to the hospital on February 1, 2025, after there was a change in their condition. There was no documentation that the facility provided written notification to the State Ombudsman as required regarding the transfer. The above information was reviewed during an interview on May 15, 2025, at 2:30 PM with the Nursing Home Administrator. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 4 of 25 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 05/16/2025 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medications one of 20 residents (Resident 50). Residents Affected - Some Findings include: Clinical record review for Resident 50 revealed a physician's order dated April 16, 2025, for Metoprolol Succinate ER (for high blood pressure) 200 milligrams (mg) by mouth twice daily for high blood pressure. Hold for systolic blood pressures (when the heart is contracting) less than 100 mmHg (millimeters of mercury) or a heart rate less than 60 beats per minute. Review of Resident 50's April and May 2025, MARs (medication administration record, a form to document medication administration) revealed that staff failed to document either a blood pressure, heart rate, or both on the following dates: April 16, 2025, at 8:00 PM April 17, 2025, at 8:00 PM April 19, 2025, at 8:00 AM and 8:00 PM April 20, 2025, at 8:00 AM and 8:00 PM April 21, 2025, at 8:00 AM and 8:00 PM April 22, 2025, at 8:00 AM and 8:00 PM April 23, 2025, at 8:00 AM and 8:00 PM April 24, 2025, at 8:00 AM April 25, 2025, at 8:00 AM and 8:00 PM April 26, 2025, at 8:00 AM and 8:00 PM April 27, 2025, at 8:00 AM and 8:00 PM April 28, 2025, at 8:00 AM and 8:00 PM April 29, 2025, at 8:00 AM May 5, 2025, at 8:00 AM May 12, 2025, at 8:00 PM Staff documented Resident 50's blood pressure as less than physician ordered parameters, but administered her Metoprolol Succinate on May 12, 2025, at 8:00 AM 96/52 mmHg. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 5 of 25 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 05/16/2025 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)

F 0684 The above information was reviewed during an interview on May 15, 2025, at 2:30 AM with the Nursing Home Administrator. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10(c) Resident care policies Residents Affected - Some 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 6 of 25 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 05/16/2025 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on clinical record review and resident and staff interview, it was determined that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion for three of four residents reviewed for range of motion concerns (Residents 13, 46, and 47). Findings include: Interview with Resident 46 on May 13, 2025, at 11:32 AM revealed that her legs are getting stiff. She indicated that she no longer goes to therapy and that she is not getting any exercise done to her legs. Clinical record review of Resident 46's task documentation revealed that staff are to complete passive range of motion (PROM, movement of a joint through range of motion by an external force) to her bilateral lower extremities. The program is set up in the task to be completed two times per day. Further review of Resident 46's task documentation related to her PROM program from April 1, 2025, to May 13, 2025, revealed that not applicable was documented 18 times, and response not required was documented 9 times. Clinical record review for Resident 47 revealed a quarterly MDS (Minimum Data Set, an assessment completed at intervals by the facility determining care needs of the resident) dated May 5, 2025, that indicated Resident 47 had an impairment on one side of his upper extremities. Clinical record review of Resident 47's care plan indicated an intervention dated September 4, 2024, for him to receive an active-assist range of motion program (AAROM, when the joint receives partial assistance from an outside force to move through range of motion) to his upper extremities. Further clinical record review revealed no evidence that Resident 47 was receiving an AAROM program to his upper extremities. Interview with the Nursing Home Administrator on May 16, 2025, at 9:30 AM confirmed that Resident 47's AAROM program was never added to his task list, so staff were unaware to do the program. Interview with the Nursing Home Administrator on May 16, 2025, at 9:30 AM confirmed the above noted finding related to Residents 46 and 47's PROM program. In an interview and observation of Resident 13 on May 14, 2025, at 2:00 PM she indicated she does not walk and has not for a long time, but pointed to her bent fingers and stated she thinks her hands and arms are getting a little bit worse. Resident 13 stated she does not receive any exercises or therapy for her arms or hands. Clinical record review for Resident 13 revealed the resident had a resident task added to her care on April 18, 2024, indicating a restorative program for active range of motion was to be completed for the resident and to see the resident's care plan for the program description. A review of Resident 13's plan of care revealed initiated on May 9, 2017, indicated the resident is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 7 of 25 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 05/16/2025 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)

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some at risk for a loss of range of motion related to arthritis and multiple sclerosis (a disease affecting the central nervous system). An intervention on the plan of care last revised on April 18, 2024, indicated the resident was to have restorative active range of motion to her bilateral upper and lower extremities with 10 repetitions with morning and evening care with a participation goal of 15 minutes twice a day. Further clinical review for Resident 13's task completion for April and May 2025, to date, revealed no evidence the range of motion program noted above was being completed with the resident as indicated. The Nursing Home Administrator confirmed the above findings in an interview on May 15, 2025, at 2:15 PM. 28 Pa. Code 211.12(d)(1)(3)(5)Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 8 of 25 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 05/16/2025 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to care for and monitor a resident's urinary catheter for one of three residents reviewed (Resident 42). Findings include: Observation of Resident 42 on May 13, 2025, at 10:10 AM and May 14, 2025, at 11:44 AM revealed that they were in bed and had a Foley (urine) catheter in place. Clinical record review for Resident 42 revealed that there was a physician's order dated May 2, 2025, for a Foley catheter to gravity. There was no physician's order that identified the size of the Foley catheter, the size of the Foley catheter balloon, or to justify the need for and implementation of Resident 42's catheter. The above information was reviewed with the Nursing Home Administrator during an interview on May 15, 2025, at 2:30 PM. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 9 of 25 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 05/16/2025 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Resident 50). Residents Affected - Few Findings include: Observation of Resident 50's room on May 13, 2025, at 10:06 AM revealed an oxygen concentrator with tubing attached. Observation of and interview with Resident 50 on May 13, 2025, at 11:28 AM revealed that there was an oxygen tank on the back of their wheelchair that was set a 3 liters per minute with oxygen being administered via a NC (nasal canula, tubing to deliver oxygen to the nose). Resident 50 stated that she needed oxygen continuously at 3 liters per minute (LPM) for respiratory concerns/diagnoses. Clinical record review for Resident 50 revealed hospital discharge instructions dated April 15, 2025, that indicated Resident 50 was discharged to the facility on oxygen 3 LPM continuously. Review of Resident 50's physician orders revealed no orders for oxygen usage in the facility. The above information was reviewed with the Nursing Home Administrator during an interview on May 15, 2025, at 2:30 PM. 28 Pa. Code 211.10 (c)(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 10 of 25 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 05/16/2025 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on staff interview, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to enteral feedings, catheter care, or intravenous therapy for two of two employees (Employees 1 and 8). Findings include: A review of the facility's current resident population documentation revealed that the facility has one resident receiving an enteral feeding (alternate form of nutrition administered via a tube), two receiving intra-venous (by vein) therapy, six with an indwelling catheter, and four residents with in-house acquired wounds. A request for nursing staff competencies for Employee 1, registered nurse, and Employee 8, licensed practical nurse, revealed facility staff could not provide any evidence either Employee 1 or Employee 8 had any competency assessments completed to appropriately perform the above care for the residents of the facility. Interview with the Nursing Home Administrator on May 15, 2025, at 2:15 PM revealed there was no evidence of nursing staff competencies available. 28 Pa Code 201.20(a) Staff development FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 11 of 25 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 05/16/2025 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)

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, review of posted daily nurse staffing data, and staff interview, it was determined that the facility failed to retain posted nursing staffing information for the past 18 months or ensure nursing staffing information was posted on three of three resident nursing units (First, Second, and Third floors). Residents Affected - Many Findings include: Observation of the facility on May 16, 2025, at 12:55 PM with the Director of Nursing revealed no evidence nursing staffing hours for the day were posted on the first, second, or third floor nursing units, or at the main entrance to the facility. Facility staff could not provide any evidence the facility retained any daily posted nursing staffing information for the past 18 months. These findings were confirmed with the Nursing Home Administrator on May 16, 2025, at 1:30 PM. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18 (d)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 12 of 25 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 05/16/2025 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)

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 Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 20). Residents Affected - Few Findings include: Clinical record review for Resident 20 revealed that the facility admitted her on July 19, 2024. Further clinical record review revealed that a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life), was added to her clinical record on July 29, 2024. A review of Resident 20's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss. The findings were reviewed with the Nursing Home Administrator during a meeting on May 16, 2025, at 9:33 AM at which time the Nursing Home Administrator confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Resident 20's dementia prior to the surveyor's questioning. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 13 of 25 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 05/16/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed pharmacy recommendations for five of six residents reviewed for unnecessary medications (Residents 20. 26, 33, 42, and 45). Findings include: Review of Resident 26's clinical record revealed a progress note dated October 10, 2024, and again on November 20, 2024, indicating that the pharmacist completed a drug regimen review for Resident 26 and to see report for recommendations. There was no documented evidence in Resident 26's clinical record to indicate what the pharmacist recommended or if it was addressed by Resident 26's physician. Review of a pharmacy recommendation dated December 9, 2024, indicated that Resident 26 has been on the same dose of Melatonin (a sleep aid) since 2022. The pharmacist recommended to evaluate the dose or consider changing it to as needed. There was no documented evidence that this recommendation was addressed by Resident 26's physician. Resident 26 remains on the same dose of Melatonin since 2022. Review of a pharmacy recommendation dated January 13, 2025, indicated that Resident 26 has been on the same dose of Haldol (an antipsychotic medication used to treat various mental disorders) since November 2023. The pharmacist recommended to evaluate the Haldol dose for a gradual dose reduction. There was no documented evidence that this recommendation was addressed by Resident 26's physician. Resident 26 remains on the same dose of Haldol since November 2023. Review of Resident 26's pharmacy recommendation dated February 13, 2025, indicated that antipsychotics have the capacity to cause tardive dyskinesia (a disorder causing involuntary movements). The pharmacist recommended that Resident 26's physician conduct testing every six months to determine if tardive dyskinesia is occurring. There was no documented evidence in Resident 26's clinical record to indicate that this was addressed by Resident 26's physician. Review of a pharmacy recommendation dated March 6, 2025, indicated that Resident 26 has been on the same dose of Ativan (treats anxiety) since October 2023. The pharmacist recommended to evaluate the Ativan dose for a gradual dose reduction. There was no documented evidence that this recommendation was addressed by Resident 26's physician. Resident 26 remains on the same dose of Ativan since October 2023. Review of Resident 33's clinical record revealed a progress note dated October 10, 2024, indicating that the pharmacist completed a drug regimen review for Resident 33 and to see report for recommendations. There was no documented evidence in Resident 33's clinical record to indicate what the pharmacist recommended or if it was addressed by Resident 33's physician. Review of a pharmacy recommendation dated December 6, 2024, indicated that Resident 33 has been on the same dose of Melatonin since August 2023. The pharmacist recommended to evaluate the dose for its need. There was no documented evidence that this recommendation was addressed by Resident 33's physician. Resident 33 remains on the same dose of Melatonin since August 2023. Review of Resident 45's clinical record revealed a progress note dated October 10, 2024, indicating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 14 of 25 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 05/16/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some that the pharmacist completed a drug regimen review or Resident 45 and to see report for recommendations. There was no documented evidence in Resident 45's clinical record to indicate what the pharmacist recommended or if it was addressed by Resident 45's physician. Review of a pharmacy recommendation dated January 9, 2025, indicated that Resident 45 has been on the same dose of Melatonin since February 2023. The pharmacist recommended to evaluate the dose for its need. There was no documented evidence that this recommendation was addressed by Resident 45's physician. Resident 45 remains on the same dose of Melatonin since February 2023. Interview with the Administrator on May 16, 2025, at 8:59 AM confirmed the above findings for Residents 26, 33, and 45. Clinical record review for Resident 20 revealed the pharmacist conducted a monthly medication review and made recommendations on December 7, 2024, and January 13, 2025, that were not addressed or addressed timely by the Resident 20's physician. Review of the pharmacist recommendation dated December 7, 2024, requested a decrease in Resident 20's Trazodone (a medication used to treat insomnia and/or depression) 75 milligrams (mg) to 50 mg at bedtime. The facility provided the surveyor with a copy of the pharmacy review, but it was not addressed or signed by the physician. Review of Resident 20's clinical record revealed that his order for Trazodone was decreased to 50 mg but not until April 7, 2025. Review of the pharmacy recommendation dated January 13, 2025, revealed a request for the physician to consider a decrease in Resident 20's Lexapro (a medication used to treat depression) 10 mg daily. The facility provided the surveyor with a copy of the pharmacy review, but it was not addressed or signed by the physician. Clinical record review for Resident 20 revealed that her Lexapro order continued at 10 mg daily. Clinical record review for Resident 42 revealed that the consultant pharmacist completed a medication review on August 12, 2024. The pharmacist identified that Resident 42 was on Celexa (an anti-depressant medication) 20 mg once daily and requested that the physician address the need for a gradual dose reduction of the medication. On September 13, 2024, Resident 42's physician addressed the pharmacist's recommendation and decreased the Celexa to 10 mg daily. On February 11, 2025, the consultant pharmacist again requested that Resident 42's Celexa 20 mg dosage be reviewed for the need of a gradual dose reduction though Resident 42 was currently on Celexa 10 mg. The physician again indicated to decrease the Celexa to 10 mg. Resident 42's Celexa 10 mg order continued since the September 13, 2024, physician's response to the pharmacist and was discontinued on March 17, 2025. There was no documentation that Resident 42's Celexa was increased back to 20 mg. Facility documentation dated May 15, 2025, revealed that the pharmacist missed Resident 42's Celexa medication being decreased due to them forgetting to update their software. The facility's contracted pharmacist failed to provide accurate information for Resident 42's medications during their monthly medication review. Further review of Resident 42's pharmacy medication review on February 11, 2025, revealed that the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 15 of 25 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 05/16/2025 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm pharmacist indicated they were on Trazodone (an anti-depressant) and Celexa for depression. The pharmacist requested a medication review to consider utilizing one anti-depressant or document the rationale for the continued use of more than one anti-depressant. There was no documentation that the physician addressed the pharmacist's medication recommendation. Residents Affected - Some Review of Resident 42's pharmacy medication review dated March 5, 2025, revealed that the pharmacist indicated they were on Olanzapine 5 mg and requested the medication be reviewed for the need of a gradual dose reduction. There was no documentation that the physician addressed the pharmacist's medication recommendation. The above information was reviewed during an interview with Nursing Home Administrator on May 16, 2025, at 8:59 AM. 483.45(c) Drug Regimen Review Previously cited 4/10/24 28 Pa. Code 211.9 (k) Pharmacy services 28 Pa. Code 211.12(d)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 16 of 25 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 05/16/2025 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of six residents reviewed (Resident 42). Residents Affected - Few Findings include: Clinical record review for Resident 42 revealed a physician's order dated March 21, 2024, for Olanzapine (for schizophrenia, a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) 5 mg (milligrams) by mouth (PO) at bedtime for schizophrenia. Review of Resident 42's clinical documentation revealed no justification for, signs and symptoms, diagnoses of, or documentation, which indicated that Resident 22 had schizophrenia. Review of Resident 42's pharmacy recommendations revealed no documentation where the consultant pharmacist identified that Resident 42's Olanzapine was ordered for schizophrenia without an appropriate diagnosis. The above information was reviewed during an interview with the Nursing Home Administrator on May 15, 2025, at 10:20 AM. 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 17 of 25 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 05/16/2025 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, review of select facility policy and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 4, 57, and 62). Residents Affected - Few Findings include: The facility's medication error rate was 10.71 percent based on 28 medication opportunities with three medication errors. The policy entitled Nasal Administration, dated September 27, 2024, indicates that nursing staff are to have the resident gently blow their nose prior to administration. During administration, nursing staff are to press a finger to the nostril not being used for administration. Observation of a medication administration pass on May 13, 2025, at 8:35 AM revealed Employee 1, licensed practical nurse, preparing to administer a saline nasal solution (helps with dry nasal passages) nose spray to Resident 57. Employee 1 administered one spray of the saline nasal spray to each of Resident 57's nostrils. Employee 1 did not have Resident 57 blow her nose or press close the opposite nostril during the administration of the saline nasal solution. Observation of a medication administration pass on May 13, 2025, at 8:42 AM revealed Employee 1 preparing to administer potassium chloride (a potassium supplement) ER (extended release) 10 mEq (milliequivalents) to Resident 62. Employee 1 crushed the potassium chloride tablet prior to administering it to Resident 62. Review of Resident 62's pharmacy card containing the potassium chloride supplement indicated to not crush the tablet. Observation of a medication administration pass on May 13, 2025, at 8:50 AM revealed Employee 1 preparing to administer a saline nasal solution nose spray to Resident 4. Employee 1 administered one spray of the saline nasal spray to each of Resident 4's nostrils. Employee 1 did not have Resident 4 blow her nose or press close the opposite nostril during the administration of the saline nasal solution. Interview with Employee 1 on May 13, 2025, at 8:52 AM confirmed the above findings. 28 Pa. Code 211.10(a) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 18 of 25 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 05/16/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 that the facility failed to store, prepare, and serve food in a manner to prevent the potential spread of foodborne illness in the main kitchen and the facility's pantry for three of three nursing units (First, Second, and Third Floor Nursing Unit; Resident 70). Findings include: Review of the 2022 Food and Drug Administration's Food Code revealed that the temperature of the wash solution in spray type ware washers (dishwashers) that use hot water to sanitize may not be less than 160 degrees Fahrenheit and the temperature of the fresh hot water sanitizing rinse as it enters the manifold may not be more than 194 degrees Fahrenheit or less than 180 degrees Fahrenheit for a single tank, conveyor, dual temperature machine. Observation of the facility's kitchen on May 13, 2025, at 9:16 AM revealed that staff were actively washing dishes through the facility's high temperature, single tank, conveyor, dual temperature dishwashing machine. The dishwasher was leaking large amounts water out of the bottom of the unit and onto the floor each time the staff sent a rack of dishes though the machine. Concurrent observation of the dishwasher's wash and final rinse temperatures revealed that the wash temperature was 146 degrees Fahrenheit, and the final rinse temperature was 156 degrees Fahrenheit. Both gauges had acceptable sanitizing temperature ranges identified on the gauge as the wash temperature range must be greater than 160 degrees Fahrenheit and the final rinse temperature must be between 180 degrees Fahrenheit and 194 degrees Fahrenheit. Kitchen staff did not identify that the dishwasher water temperatures were not at or within the appropriate temperatures to sterilize and sanitize dishes to prevent the potential for foodborne illness. Kitchen staff continued to utilize the dishwasher after the low water temperatures were identified by the surveyor. The facility's dishwasher temperatures did not meet temperatures to properly sanitize the facility's dishes. Observation of the Third Floor Nursing Unit's pantry on May 16, 2025, at 10:45 AM revealed that there was an undated, unlabeled container with a grilled sandwich inside the refrigerator. Observation of the First Floor Nursing Unit's pantry on May 16, 2025, at 10:50 AM revealed that there was an opened box of chocolate oatmeal pies labeled and available for Resident 70's use. The use by date was May 11, 2025. Observation of the Second Floor Nursing Unit's pantry on May 16, 2025, at 10:54 AM revealed that there was an undated, unlabeled, open container of corn soup with a use by date of May 14, 2025, inside the refrigerator. The above information was reviewed with the Nursing Home Administrator during an interview on May 13, 2025, at 10:20 AM and May 16, 2025, at 11:01 AM. 483.60(i)(1)(2) Food Procurement. store/prepare/serve Sanitary (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 19 of 25 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 05/16/2025 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)

F 0812 Previously cited 4/10/24 Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.14 (a) Responsibility of licensee Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 20 of 25 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 05/16/2025 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)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on review of Quality Assurance meeting attendance records and staff interview, it was determined that the facility failed to conduct Quality Assurance and Performance Improvement (QAPI) meetings at least quarterly with all the required committee members for four of four quarters (May 2024, through May 2025). Residents Affected - Some Findings include: Review of facility's Quality Assurance and Performance Improvement (QAPI) Committee Meeting Attendance Records from May 2024, to May 2025, revealed the facility failed to have an Infection Preventionist in attendance for any of the meetings held in the noted time frame as required to attend at least quarterly. The Nursing Home Administrator indicated in an interview on May 16, 2025, at 12:00 PM that the facility has been without an Infection Preventionist since July 2024, and there was no evidence the Infection Preventionist attended a QAPI meeting in May or June 2024. The facility failed to have all the required QAPI committee members present at least quarterly as required. Cross refer F882, F880 28 Pa Code: 201.18(e )(1)(2) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 21 of 25 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 05/16/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions for one of 24 residents reviewed (Residents 52). Residents Affected - Few Findings included: Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care. Review of the facility's current policy entitled Enhanced Barrier Precautions, revealed it is the facility's policy to use EBP in addition to Standard Precautions (infection control practices used for all patients) when Contact precautions (heightened infection control measures to prevent the spread of infections) do not otherwise apply, or when a resident has a targeted multi-drug-resistant organisms (MDROs - bacteria that have developed resistance to one or more antimicrobial drugs). The policy also indicated when EBP are needed an appropriate EBP sign will be placed on the patient's room door, and personal protective equipment (PPE) should be readily accessible and located outside the patient's room. The PPE is to be used during high contact patient care activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, device care, or assisting with toileting. Before exiting the room, the PPE is to be placed in the trash and hand hygiene performed upon exiting the room. An observation of Resident 52's room on May 13, 2025, at 10:50 AM revealed the resident was out of the room. A sign was observed on the door to the room indicating Stop - Standard Precautions plus Droplet Precautions (infection control measures to prevent the spread of diseases that are transmitted through respiratory droplets), and to wear a gown, gloves, and mask to enter the room. There were no PPE bins containing gowns or masks outside the room or near the room, nor were any PPE disposal bins observed in the room or directly outside the door to the room. In an interview with Employee 7, nurse aide, on May 13, 2025, at 11:21 AM who was working in the hallway where Resident 52 resided, indicated she was not sure why the sign was on Resident 52's door and was not aware Resident 52 or any of his roommates were on any precautions, and indicated the sign may not have been removed from flu season. In an interview with the Nursing Home Administrator on May 13, 2025, at 12:33 PM it was determined that neither Resident 52 nor any of his roommates were to have Droplet Precautions and the sign was from an old instance and had not been removed from the door, but Resident 52 is to have EBP in place due to a history of an MDRO per the facility policy. Clinical record review for Resident 52 revealed the resident has a history of draining wounds on his bilateral lower extremities, and per a lab report result dated December 31, 2024, the resident's wound culture was positive for Methicillin-Resistant Staphylococcus aureus (MRSA, bacteria resistant to several antibiotics, an MDRO). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 22 of 25 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 05/16/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm An observation of Resident 52 on May 14, 2025, at 9:30 AM revealed the resident wheeling himself out of his room in a wheelchair. The Droplet Precautions sign on the door noted above had been removed and no signage appeared on the door indicating any additional precautions were needed for any of the resident's residing in Resident 52's room. Resident 52 was observed to have bandages wrapped around his lower legs. Residents Affected - Few In an interview with the Nursing Home Administrator on May 14, 2025, at 11:18, she indicated Resident 52 was indeed on EBP, and the signage should have been changed on the resident's door to the room with PPE supplies placed outside the room, when it was brought to the facility's staff attention on May 13, 2025. Clinical record review for Resident 52 on May 15, 2025, at 12:31 PM revealed Special Instructions were now added in Resident 52's electronic record indicating the resident was to have EBP for draining wounds. In an interview with the Nursing Home Administrator and Director of Nursing on May 15, 2025, at 2:30 PM it was confirmed Resident 52 should have had EBP in place with appropriate signage on the resident's door and availability of the required PPE should have been available outside the resident's room. An observation of Resident 52's room on May 16, 2025, at 12:27 PM revealed no signage indicating EBP was located on Resident 52's door to alert staff and visitors that additional precautions were needed for the resident prior to entering the room nor were the required PPE supplies located outside the room and readily available. Cross refer F868, F882 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 23 of 25 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 05/16/2025 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)

F 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on staff interview, it was determined that the facility failed to have a designated Infection Preventionist with the necessary qualifications responsible for the facility's infection prevention and control program. Findings include: Interview with the Nursing Home Administrator on May 13, 2025, at 9:15 AM revealed that the facility's previous Director of Nursing fulfilled the position of infection preventionist until July 2024, at which time she stepped down as the Director of Nursing into another position within the facility and is no longer employed by the facility. The interview indicated that the facility currently does not have an infection preventionist and has not had one since July 2024. Interview with the Nursing Home Administrator on May 15, 2025, at 2:30 PM confirmed the above findings regarding the infection preventionist position. 28 Pa. Code 201.18(b)(1)e)(1)(3)(6) Management 28 Pa. Code 201.19(3) Personnel policies and procedures 28 Pa. Code 211.12(c)(d)(1)(4)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 24 of 25 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 05/16/2025 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)

F 0887 Level of Harm - Minimal harm or potential for actual harm Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on clinical record review and staff interview, it was determined that the facility failed to offer and administer a COVID immunization for one of five residents reviewed for immunizations (Resident 69). Residents Affected - Few Findings include: Clinical record review revealed the facility admitted Resident 69 on October 8, 2024. Review of Resident 69's clinical record revealed no documentation of any COVID-19 vaccines. Review of Resident 69's COVID 19 vaccine consent form date October 8, 2024, revealed a signed consent requesting the facility administer the current CDC recommended COVID vaccine. There was no additional information in Resident 69's clinical record that the facility offered or administered Resident 69 a COVID immunization since admission October 8, 2024. Interview with the Nursing Home Administrator on May 16, 2025, at 10:35 AM confirmed these findings. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 25 of 25