Health inspection·August 14, 2025

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete evening shiftJuly 26, 2025, day shiftJuly 27, 2025, day shift and evening shift The Documentation Survey Report dated July 2025, indicated that staff failed to provide toilet/bladder/bowel assistance to Resident 5 on the following dates and shifts: July 1, 2025, day shift and evening shiftJuly 5, 2025, day shiftJuly 9, 2025, evening shiftJuly 10, 2025, day shiftJuly 11, 2025, day shiftJuly 12, 2025, evening shiftJuly 14, 2025, day shiftJuly 15, 2025, evening shiftJuly 21, 2025, evening shiftJuly 22, 23, 24, and 25, 2025, day shiftJuly 27, 2025, evening shiftJuly 30 and 31, 2025, day shift The surveyor reviewed the above concerns regarding Resident 5's activities of daily living care during an interview with the Nursing Home Administrator and the Director of Nursing on August 14, 2025, at 3:30 PM. Observation of Resident 7 on August 14, 2025, at 10:43 AM revealed she was in bed. Interview with Employee 3 on the date and time of the observation revealed that she just completed Resident 7's morning care. Employee 3 stated that skilled therapy staff would arrive on the unit before lunch and staff would transfer Resident 7 out of bed to leave the nursing unit at that time. Observation of the second-floor nursing unit on August 14, 2025, at 11:09 AM revealed staff transported Resident 7 in a wheelchair onto the elevator to leave the nursing unit. Clinical record review for Resident 7 revealed a plan of care developed by the facility to address her activities of daily living self-care deficit (last revised June 1, 2022) that listed interventions that included: Transfer with mechanical full body liftOut of bed to geri (geriatric) lounge chairAssist with daily hygiene, grooming, dressing, oral care, and eating as needed Observation of Resident 7 on August 14, 2025, at 1:46 PM revealed she was in her wheelchair outside her room door. Interview with Employee 3 on August 14, 2025, at 1:48 PM revealed that Resident 7 was not transferred out of her wheelchair (via a total lift) or provided incontinence care since she provided her morning care (completed at 10:43 AM). Observation of Resident 7 on August 14, 2025, at 2:30 PM revealed that Employee 3 and Employee 2 transported Resident 7 into her room with a lift device to provide care. A plan of care developed by the facility to address Resident 7's incontinence of bowel and bladder (last revised April 1, 2019) revealed interventions that included to See Task list for individualized toileting plan. Review of a Documentation Survey Report (Task list documentation) dated August 2025, for Resident 7 revealed the Intervention/Task of Individual Toileting Plan: after breakfast and Lunch before super and after super, HS (hour of sleep/bedtime), all rounds on 11-7 (11:00 PM to 7:00 AM) and as needed, was initialed as completed by Employee 3 on August 14, 2025, at 2:59 PM although no staff assisted Resident 7 with toileting after lunch on this date. Resident 7 did not receive incontinence care for the almost four hours reviewed or incontinence care after lunch per her toileting program. The surveyor reviewed the above concerns regarding Resident 7's activities of daily living care during an interview with the Nursing Home Administrator and the Director of Nursing on August 14, 2025, at 3:30 PM. 28 Pa. Code 211.12(d)(1)(5) Nursing services Event ID: Facility ID: 395359 If continuation sheet Page 2 of 5 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 08/14/2025 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 a review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier precautions for three of four residents reviewed for infection control concerns (Residents 1, 2, and 3).Findings include: Review of the Center for Medicaid and Medicare Services (CMS) memo entitled, Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms, released by 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 (e.g., 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, last revised December 16, 2024, revealed that EBP is defined as an infection control intervention designed to reduce the transmission of novel or multi-drug-resistant organisms (MDROs, bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial medications). It employs targeted personal protective equipment (PPE) use during high-contact resident activities. Use EBP for a resident with a wound or indwelling medical device. The policy referred to an Enhanced Barrier Precautions procedure. Review of the facility's, Procedure: Enhanced Barrier Precautions, revealed that the first step is for staff to post the appropriate EBP sign on the resident's room door. For all residents with a chronic wound and/or an indwelling medical device (e.g., urinary catheter) staff are required to use a gown and gloves prior to high-contact care activities which include: dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care. Clinical record review for Resident 3 revealed her diagnoses list included: Urinary tract infection (infection of any part of the urinary system such as the urethra, bladder, ureters, or kidneys)Neuromuscular Dysfunction of Bladder (neurogenic bladder, communication between the brain and bladder malfunctions and can cause retention of urine)Bacteremia (presence of bacteria in the blood)Pressure ulcer of the sacrum, Stage IV (wound with full-thickness skin and tissue loss over the area at the base of the spine) Active physician orders for Resident 3 included: Change Indwelling catheter when occluded or leaking as needed (dated August 8, 2025) Indwelling catheter 16FR (diameter size of tubing, size 16 French) with 10 ml (milliliters) balloon to bedside straight drainage for diagnosis of neuromuscular dysfunction of bladder (dated August 8, 2025) Wound: Negative Pressure Wound Therapy (wound vac, gentle suction applied to the wound bed to improve the wound environment and promote healing of complicated wounds) to buttocks. Cleanse with wound cleanser, place gauze/black into wound, apply skin prep (liquid protective skin barrier) to intact skin around the wound, and window tape the peri-wound (area around the wound) with a transparent dressing. Cover with occlusive transparent dressing and secure tubing per manufacturer guide every day shift every three day(s) for sacral wound and as needed for soilage or dislodgement (dated August 8, 2025) If wound vac malfunctions, stop the wound vac, remove the dressing, cleanse the area with wound cleanser, and apply a dry dressing. Notify the provider (dated August 8, 2025) Nursing documentation dated August 12, 2025, at 2:50 PM revealed that staff noted Resident 3 had a urinary catheter intact, and she had a pressure ulcer on her sacrum and coccyx (tailbone, triangular shaped bone at the end of the spine). Observation of Resident 3's room door on August 14, 2025, at 9:45 AM revealed an EBP sign that Bed C (Resident 3's bed assignment in the three-bed room) required EBP. Observation of the room revealed four individuals (three facility staff and one staff from the facility's contracted transport company) transferring Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 3 of 5 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 08/14/2025 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 Residents Affected - Some Resident 3 from her bed to a wheelchair. None of the four individuals observed were wearing an isolation gown. The contracted transport company staff propelled Resident 3's wheelchair out of the room and the tubing and collection container of an indwelling urinary catheter was observed near Resident 3's lower legs and feet. Observation of Resident 3's room on August 14, 2025, at 2:04 PM revealed Employee 2 (nurse aide) with the facility's contracted transport company staff returned Resident 3 to her room. Employee 2, Employee 3 (nurse aide), and Employee 6 (nurse aide), donned gloves to begin transferring Resident 3 from the wheelchair to her bed. Resident 3's indwelling urinary catheter collection bag and tubing was visible. The staff requested additional assistance from Employee 1 (licensed practical nurse) to complete the transfer. Employee 1 donned gloves. None of the four individuals donned an isolation gown before transferring Resident 3 from her wheelchair to her bed. Employees 3 and 6 changed Resident 3's incontinence brief during the observation without donning an isolation gown. The surveyor reviewed the above concerns regarding EBP for Resident 3 during an interview with the Nursing Home Administrator and the Director of Nursing on August 14, 2025, at 3:30 PM. Clinical record review for Resident 2 revealed active physician orders for staff to complete a treatment to Resident 2's left lower leg daily in the evening and as needed for dislodgement. Observation of Resident 2's room door on August 14, 2025, at 9:51 AM revealed a sign for EBP; however, the sign indicated that only Bed C in the room (the resident closest to the window) required EBP. Resident 2 was assigned the first bed, Bed A, the bed closest to the door. Observation of Resident 2's left lower leg with Employee 1 on August 14, 2025, at 9:54 AM revealed that she had a dressing covering the middle of her left lower leg. Employee 1 confirmed that evening shift staff complete a dressing change to Resident 2's left lower leg daily. Observation of Resident 2 on August 14, 2025, at 1:38 PM revealed that she was yelling, and she wanted to get out of bed. Observation of Employees 1 and 3 on August 14, 2025, at 1:48 PM revealed they donned gloves (but did not don an isolation gown) before changing Resident 2's incontinence brief and transferring Resident 2 from her bed to her wheelchair via a full-body mechanical lift. Once Resident 2 was in her wheelchair, Employee 1 completed a full linen change of her bed. Employee 1 was not wearing an isolation gown. Interview with Employee 1 on August 14, 2025, at 2:19 PM confirmed that the EBP sign on Resident 2's door did not indicate that EBP were necessary for Resident 2 although Resident 2 had a wound that required daily treatment. Employee 1 confirmed that the PPE used for Resident 2's care was limited to glove use, and staff did not utilize an isolation gown for her high-contact care (that included dressing, transferring, changing her incontinence brief, and changing her linens). The surveyor reviewed the above concerns regarding the implementation of EBP for Resident 2 during an interview with the Director of Nursing and the Nursing Home Administrator on August 14, 2025, at 3:30 PM. Clinical record review for Resident 1 revealed active physician orders for staff to provide care to: A right flank and left flank nephrostomy tube (thin, flexible tubing surgically inserted through the side and directly into the kidney for the purpose of draining urine) daily and as neededA left inner thigh wound every shift and as neededA sacral wound every shift and as needed Nursing documentation dated August 13, 2025, at 6:38 PM revealed that staff admitted Resident 1 to the facility, and she had nephrostomy tubes draining urine into bags at her bedside. Observation of Resident 1's room door on August 14, 2025, at 2:32 PM revealed an EBP sign that indicated the residents in the B and D beds required EBP. Resident 1 resided in the C bed (bed closest to the window on the right side of the room). Observation of the second-floor nursing unit on August 14, 2025, at 2:35 PM revealed that Employee 5 (nurse aide) attempted to assist Resident 1 to transfer from her wheelchair to her bed; however, Employee 5 did not don an isolation gown to assist Resident 1 to transfer. Interview with Employee 4 (licensed practical nurse) on August (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 4 of 5 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 08/14/2025 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 Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 14, 2025, at 2:39 PM confirmed that the sign on Resident 1's door did not indicate that she required EBP; however, she did due to the presence of nephrostomy tubes. Employee 4 obtained a marker and added, Bed C, to the sign on Resident 1's room door. During continued observation of Resident 1's room on August 14, 2025, at 2:42 PM Employee 5 requested additional assistance from Employee 4 to transfer Resident 1 to her bed. Employee 4 entered the room, did not don an isolation gown, and with the extensive physical assistance of Employees 4 and 5 (neither wearing an isolation gown), Resident 1 transferred from her wheelchair to her bed. Interview with Employee 7 (registered nurse) on August 14, 2025, at 2:42 PM while observing the staff transfer Resident 1, confirmed that the staff did not don an isolation gown to perform the high-contact activity. Employee 7 indicated that she was not familiar with Resident 1 due to her recent admission; however, the facility's infection preventionist would want a resident with indwelling nephrostomy tubes to have EBP in place. The surveyor reviewed the above concerns regarding the implementation of EBP for Resident 1 during an interview with the Nursing Home Administrator and the Director of Nursing on August 14, 2025, at 3:30 PM. 483.80 Infection ControlPreviously cited deficiency 5/16/25 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Event ID: Facility ID: 395359 If continuation sheet Page 5 of 5