Health inspection·October 1, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete noted treatments was reviewed with the Director of Nursing and Nursing Home Administrator on October 1, 2025, at 3:30 PM. There was no additional information to indicate whether the treatments were completed as ordered or that the resident had refused or was not available for the treatment to be completed. The Director of Nursing indicated Resident 4 utilized a different negative pressure machine for his wound than others in the facility and supply delivery was delayed, which may have impacted Resident 4's treatments. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services Event ID: Facility ID: 395359 If continuation sheet Page 2 of 4 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 10/01/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies, clinical record review, and resident and staff interview, it was determined that the facility failed to provide timely medications to one of five residents reviewed (Resident 3) and failed to obtain and provide medications for one of five residents reviewed (Resident CR1). Findings include: Review of the facility's current policy entitled Medication Administration General Guidelines, revealed it is the facility's policy that medications are administered within 60 minutes of scheduled times, except before or after meal orders, which are administered based on mealtimes. In an interview with Resident 3 on October 1, 2025, at 3:14 PM the resident indicated she sometimes needs to tell staff she needs her medications because they are late. Resident 3 stated she used to get her morning medication closer to 8:00 AM but it has been closer to 10:30 AM at times, and that she believes her medication times were going to change because staff were working on two floors. Review of Resident 3's medication administration record for September 2025, revealed the following medications administered outside the 60-minute window of the scheduled administration time. Breo Ellipta Inhalation Aerosol Powder (a maintenance medication to assist with breathing conditions) scheduled for 8:00 AM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, and 29, 2025. Diltiazem HCL Extended Release (used to treat blood pressure) scheduled for 8:00 AM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, and 29, 2025. This medication was also ordered to be held for the resident for a systolic blood pressure (top/upper number, pressure when your heart beats) less that 90, and a heart rate less than 50. There was no evidence that Resident 3's blood pressure or heart rate was checked prior to the administration of this medication on September 27, 28, 29 or 30, 2025. Eliquis (blood thinner) scheduled for administration two times a day at 8:00 AM and 8:00 PM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, and 29, 2025, and too early for the second dose between 5:00 PM and 6:00 PM on the same days the morning dose was administered late on September 26, 27, and 28, 2025. The resident was not documented as being administered, the evening dose on September 29, or the morning or evening dose on September 30, 2025. There was no evidence to indicate the resident refused or was not available for staff to administer the medication. Metoprolol Succinate Extended Release (blood pressure and heart medication) scheduled to be given one time a day at 8:00 AM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, 29, 2025. The medication was also ordered to be held for a systolic blood pressure less than 90 and a heart rate less than 50. There was no evidence that Resident 3's blood pressure or heart rate was checked prior to the administration of this medication on September 27, 28, 29 or 30, 2025. Potassium Chloride Extended Release (mineral supplement to maintain fluid balance and heart and kidney function) scheduled to me administered three times a day at 6:00 AM, 2:00 PM, and 8:00 PM was not documented as administered for the 6:00 AM dose on September 16, and 24, and late between 9:00 AM and 10:00 AM on September 30th, 10:00 and 11:00 AM on September 26, 27, 28, 29, 2025. Resident 3 was then documented as receiving the next dose of the extended-release medication within the scheduled time of 1:00 PM - 3:00 PM (one hour before/after scheduled 2:00 PM) potentially leaving only 4 hours between doses. Tylenol (mild pain reliever) scheduled to be administered two times a day at 8:00 AM and 8:00 PM was administered late between 10:00 and 11:00 AM on September 26, 27, 28, 29, 2025, and the evening dose was documented as being administered early between 5:00 and 6:00 PM on September 26, 27, and 28, 2025, three of the same days the morning dose was administered late. The resident was not documented as being administered, the evening dose on September 29, or the morning or evening dose on September 30, 2025. There was no evidence to indicate the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395359 If continuation sheet Page 3 of 4 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 10/01/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete resident refused or was not available for staff to administer the medication. In an interview with the Director of Nursing on October 1, 2025, at 2:30 PM she indicated Resident 3 is permitted to self-administer medications, but the time documented on the Medication Administration Record would be the time staff provided the resident with the medication. Closed clinical record review for Resident CR1 revealed the resident was re-admitted to the facility on [DATE], from the hospital where the resident was being treated for a wound of the left foot and returned to the facility with a PICC line (flexible tube inserted into a vein used for long-term intravenous medication administration). A facility physician history and physical note dated August 22, 2025, at 8:02 PM indicated that Resident CR1 was admitted and treated at the hospital for a left foot abscess, and was discharged from the hospital with Levofloxacin (potent, broad-spectrum antibiotic used to treat bacterial infections), 750 milligrams to be given orally every 48 hours, and Vancomycin (powerful antibiotic used for systemic infections throughout the body), to be given intravenously (IV) every 24 hours until September 27, 2025. The physician's plan indicated to continue the Vancomycin and Levofloxacin as directed. There was no evidence Resident CR1 was ordered Levofloxacin or Vancomycin upon admission to the facility on August 22, 2025. Review of Resident CR1's physician orders revealed Vancomycin as noted above was not ordered and administered until August 25, 2025, three days later, and Levofloxacin was not ordered until August 27, 2025, and administered on August 28, 2025, six days later. A follow up physician's note dated August 27, 2025, at 10:10 PM indicated that staff did not transcribe the Vancomycin order because it was not clearly documented on the hospital discharge instructions from the hospital and noted facility nursing staff contacted the provider on August 22, 2025, indicating the resident had a PICC line and needed IV medication and was advised to talk to the hospital discharging physician about which IV antibiotic, and noted the IV antibiotic was never transcribed and was not given noting the resident missed two doses (August 23, and 24, 2025). The note did not address the Levofloxacin not being ordered or administered. Results of a Vancomycin trough (lab measure obtained to assess the concentration of the antibiotic in the bloodstream to ensure the drug is at a level high enough to be effective and not too high to be toxic) ordered and obtained on August 25, 2025, revealed a level of 9 ug/ml (microgram/milliliter) below the desired minimum level of 10. Review of Resident CR1's hospital discharge instructions revealed one page of the resident's medications and discharge instructions was missing (page 9 of a 23-page document), of which facility staff indicated would have contained the IV medication and the Levofloxacin. It could not be determined if the page was available upon the resident's admission. Resident CR1 did not receive the antibiotics as noted above and noted by the physician on August 22, 2025, upon admission to the facility to continue as part of the resident's plan of care. The above findings regarding Resident 3's timing of medication administration, and Resident CR1's missed doses of antibiotics were reviewed with the Nursing Home Administrator and Director of Nursing on October 1, 2025, at 3:30 PM. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy services 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services Event ID: Facility ID: 395359 If continuation sheet Page 4 of 4