Health inspection·March 8, 2024

F 0584 is not good and pointed out the dust on his/her stands. Level of Harm - Minimal harm or potential for actual harm Observations made at the time of the interview, revealed fuzzy dust located on Resident R5's window/shelf area and dresser. Residents Affected - Some During an interview and tour on 3/6/24, at approximately 12:30 p.m. Registered Nurse Employee E1 confirmed the dirty conditions in the common areas and resident's rooms on the second floor of the facility, including what appeared to be dry fecal matter on Resident R11's floor and noted his/her shoes sticking the floor during the tour. During an interview on 3/6/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that housekeeping was an issue within the facility. 28 Pa. Code 201.18 (b)(1)(3) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 2 of 7 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 395626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Penn Highlands Jefferson Manor 417 Route 28 Brookville, PA 15825 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 review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to perform tracheostomy (surgical procedure that creates an opening in the neck to place a tube into the windpipe) care per physician's orders for one of one residents reviewed (Resident R2). Residents Affected - Few Findings include: Review of a facility policy entitled, Tracheostomy-Routine Care of Dressing Changes/Skin Care/Inner Cannula Care dated 2/14/24, indicated, RN (Registered Nurse) completing care to document dressing change on resident treatment record located in the resident's EMR (Electronic Medical Record) .Document completion of care on resident treatment record in the resident's EMR. Review of Resident R2's clinical record revealed an admission date of 11/04/96, with diagnoses that included cerebral palsy (congenital disorder of movement/muscle tone/posture), aphasia (language disorder that affects ability to communicate), respiratory failure, and hypoglycemia (low blood sugar). A physician's order dated 4/30/20, identified to provide tracheostomy care and change tracheostomy sponge every day and evening shift for Resident R2. Resident R2's Electronic Treatment Administration Record (ETAR) for February 2024 and March 2024, revealed 19 days (2/1/24, 2/6/24, 2/7/24, 2/8/24, 2/10/24, 2/11/24, 2/13/24, 2/14/24, 2/15/24, 2/18/24, 2/19/24, 2/24/24, 2/26/24, 2/28/24, 2/29/24, 3/1/24, 3/2/24, 3/4/24, and 3/5/24) that lacked evidence indicating tracheostomy care was completed per physician orders. During an interview with RN Employee E1 on 3/6/24, at 2:25 p.m. revealed he/she did not perform tracheostomy care for Resident R2 on 3/5/24. During an interview on 3/7/24, at 3:22 p.m. the Director of Nursing confirmed that Resident R2's ETAR lacked evidence that tracheostomy care was completed due to incomplete documentation. 28 Pa. Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 3 of 7 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 395626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Penn Highlands Jefferson Manor 417 Route 28 Brookville, PA 15825 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on review of facility policy, facility documents, and clinical records, and staff and resident interviews, it was determined that the facility failed to have sufficient staff with the appropriate skill sets to provide nursing services. Findings include: A facility policy entitled Nursing Department Staffing dated 2/14/24, indicated, This facility provides sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, psychosocial and spiritual well being of residents and Sufficient personnel are assigned and on duty to assure safe effective nursing care, including relief personnel during vacations, holidays, and sick leaves. Review of resident council minutes dated 12/22/23, and 2/3/24, indicated that residents feel the facility needs more staff and that call bells are not being answered timely on evening shift and on overnight shift. Facility nurse staffing reviewed for 3 weeks and included 3/3/24 revealed on 2/11/24, Certified Nursing Assistant (CNA) ratios were not met on dayshift, on 2/16/24, CNA ratios were not met on evening shift, on 2/17/24, CNA ratios were not met on dayshift, evening shift, and the minimum Per Patient Day (PPD) was not met, on 2/18/24, CNA ratios were not met on evening shift and the minimum PPD was not met, on 2/29/24, the minimum PPD was not met, on 3/1/24, CNA ratios were not met on evening shift and overnight shift, on 3/2/24, the CNA ratios were not met on evening shift, overnight shift, and the minimum PPD was not met, and on 3/3/24, the CNA ratios were not met on dayshift and the minimum PPD was not met. Clinical documentation for Resident R3 on 2/03/24, revealed that Resident R3 was ordered for the Licensed Practical Nurse (LPN) to obtain vital signs every shift for 72 hours, then daily, and to chart under vitals in the electronic medical record and daily skilled charting. The LPN documented in the progress notes at 10:59 a.m. and 11:00 a.m. that the LPN was unable to complete due to floating (same staff person has to work between different areas within the facility) to two different halls. Clinical documentation for Resident R4 on 2/03/24, revealed that Resident R4 was ordered for the LPN to obtain vital signs monthly and chart under vitals in the electronic medical record every day shift every 1 month(s) starting on the third for 1 day(s). The LPN charted in the progress notes at 1:27 p.m. unable to complete due to floating to two floors. Clinical documentation for Resident R5 on 2/03/24, revealed that Resident R5 was ordered to be weighed daily with mechanical lift for congestive heart failure. The LPN charted in the progress notes at 1:45 p.m. unable to complete due to floating to two floors. Clinical documentation for Resident R8 on 2/03/24, revealed that Resident R8 was ordered for the LPN to do a weekly skin evaluation every afternoon, every Saturday. The LPN charted in the progress notes at 1:46 p.m. unable to complete due to floating to two floors. Clinical documentation for Resident R6 on 2/03/24, revealed that Resident R6 was ordered 15-minute visual safety checks. The LPN charted in the progress notes from 1:49 p.m. to 10:02 p.m. unable to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 4 of 7 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 395626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Penn Highlands Jefferson Manor 417 Route 28 Brookville, PA 15825 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 0725 complete due to floating to two floors. Level of Harm - Minimal harm or potential for actual harm Clinical documentation for Resident R7 on 2/03/24, revealed that Resident R7 was ordered Zinctral External Paste (topical treatment for a skin wound) to be applied to the sacrum/coccyx/buttocks every shift as a preventative. The LPN charted in the progress notes at 1:52 p.m. unable to complete due to floating to two floors. Residents Affected - Many Clinical documentation for Resident R2 on 3/05/24, revealed that Resident R2 was ordered for the Registered Nurse (RN) to provide tracheostomy (trach-surgical procedure that creates an opening in the neck to place a tube into the windpipe) care and change trach sponge every day and evening shift. The treatment record lacked evidence that trach care was provided on 3/05/24. Staff interview conducted with RN Employee E1 on 3/6/24, at 12:30 p.m. revealed that resident treatments are being missed due to working short staffed and LPNs floating from second floor to third floor. At 2:25 p.m., he/she revealed they did not perform tracheostomy care for Resident R2 on 3/05/24, due to working short staff and not having time. Staff interview conducted with CNA Employee E2 on 3/6/24, at 11:15 a.m. revealed he/she is often alone on a hall with 20 or more residents with a float who covers several halls. Staff interview conducted with CNA Employee E3 on 3/6/24, at 11:30 a.m. revealed over the weekend he/she was alone on his/her hall with 24 residents and the LPN could not assist with resident care because the LPNs were floating and busy doing the medications and treatments. He/She knows residents were sitting soiled for extended periods of time and that the meal carts sat for over 30 mins before the trays could be passed. Staff interview conducted with LPN Employee E4 on 3/6/24, at 11:20 a.m. revealed LPNs are often floating from second to third floor and LPNs are forced to take over two medication carts. He/She expressed concern regarding floating because it is unsafe, and the nurses are more likely to make mistakes. Additionally, the LPNs try to assist the CNAs who are often working short staff with resident care. Staff interview conducted with LPN Employee E5 on 3/6/24, at 11:35 a.m. revealed LPNs are forced to take over two medication carts and float from second to third floor frequently and although they may be meeting the staff ratios, this is unsafe, and they feel pressured to take the second medication cart even if they don't want to. Staff interview conducted with CNA Employee E6 on 3/6/24, at 12:40 p.m. revealed he/she is often alone on the third floor with 15 or more residents and revealed he/she must wait for assistance for maxi-lift (mechanical lift requiring more than one staff person to assist a resident) residents from a CNA float or the LPN when not busy doing their job. He/She confirmed there are several maxi-lift residents, and this requires two staff members. Staff interview conducted with CNA Employee E7 on 3/6/24, at 12:45 p.m. revealed he/she has been a float several times and in one day has floated from one side of the second floor with 20 plus residents', to the locked memory care unit with 15 plus residents, and up to the third floor with 15 plus residents. he/she fears this is not safe leaving the other CNAs alone to float to several halls on different floors, and feels it is especially unsafe on the memory care unit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 5 of 7 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 395626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Penn Highlands Jefferson Manor 417 Route 28 Brookville, PA 15825 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Staff interviews conducted with LPN Employee E8 and RN Employee E9 on 3/6/24 at 1:00 p.m. revealed they assist with medication pass at times and that they have witnessed LPNs taking over two medication carts and floating from the second to the third floor. Interview conducted with Resident R11 on 3/6/24, at approximately 11:17 a.m. revealed he/she is independent so does not need as much help from the staff, but he/she is concerned with the short staff for the residents that really need the help. He/She stated they are always running short and fears it is affecting care. Review of Resident R11's Brief Interview for Mental Status (BIMs-15-point cognitive screening measure that evaluates memory and orientation) evaluation dated 3/4/24, revealed a score of 14 and was cognitively intact. Interview conducted with Resident R10 on 3/6/24, at approximately 11:32 a.m. revealed he/she is concerned with the staffing and stated, they need more help. Review of Resident R10's BIMS evaluation dated 2/12/24, revealed a score of 14 and was cognitively intact. Interview conducted with Resident R5 on 3/6/24, at approximately 11:50 a.m. revealed the staffing in the facility is not good and stated, the residents can sense the staff is stressed out, rushed, and overwhelmed. Review of Resident R5's BIMS evaluation dated 2/2/24, revealed a score of 13 and was cognitively intact. During an interview on 3/6/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to meet the required CNA ratios and minimum PPD for the dates listed above, and that the facility needs to work on the provision of adequate staffing levels. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(4) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 6 of 7 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 395626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Penn Highlands Jefferson Manor 417 Route 28 Brookville, PA 15825 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to have complete and accurate documentation regarding wound dressing changes for one of three residents reviewed with wounds in the treatment record (Resident R1). Findings include: Review of facility policy entitled Documentation, dated 2/14/24, indicated, Treatments done will be charted in the Electronic Treatment Administration Record (ETAR) .Document information as soon as possible to ensure accuracy of the information and to reflect ongoing care. Review of facility policy entitled Dressing change Protocol, dated 2/14/24, indicated, Initial completion on Treatment Administration Record. Review of Resident R1's clinical record revealed an admission date of 10/13/22, with diagnoses that included pain, weakness, seizures, and chronic kidney disease. The clinical record revealed that on 2/20/24, R1's physician ordered a wound dressing change to be completed daily and as needed. Resident R1's ETAR for February 2024, revealed five days (2/21/24, 2/22/24, 2/23/24, 2/24/24, and 2/25/24) that lacked documentation indicating the wound dressing change was completed per physician orders. During an interview on 3/07/24, at 3:22 p.m. the Director of Nursing confirmed that Resident R1's treatment records did not have complete documentation regarding wound dressing changes. 28 Pa. Code 211.5(f)(xiii)(ix) Medical Records 28 Pa. Code 211.12(d)(1)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 7 of 7