Health inspection·April 10, 2024

F 0657 times. Level of Harm - Minimal harm or potential for actual harm Interview on 4/09/24, at 12:36 p.m. with the Nursing Home Administrator and Director of Nursing confirmed that Resident R3's care plans related to call bell use and tap bell use were confusing and the call bell interventions should have been updated when the tap bell was ordered. Residents Affected - Few 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: 395626 If continuation sheet Page 2 of 9 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 04/10/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and clinical records, and resident and staff interviews, it was determined that the facility failed to follow physician's orders related to safe transfers for five of seven residents reviewed (Residents R6, R10, R11, R16, and R17). Residents Affected - Some Findings include: A facility policy entitled Mechanical Lift Policy dated 4/20/23, indicated that at least two qualified nursing personnel are required to always operate mechanical (designed to lift and transfer patients from one place to another) lifts. Resident R6's clinical record revealed an admission date of 5/31/21, with diagnoses that included broken right lower leg, stoke, abnormal gait/mobility, and spinal stenosis (condition that happens when the space inside the backbone is too small and can put pressure on the spinal cord and nerves that travel through the spine). Resident R6's clinical record revealed a physician's order dated 11/28/22, to transfer with a mechanical lift and assistance of two. A current care plan entitled impaired mobility included to use a mechanical lift to use the shower. Resident R6's clinical record revealed an annual Minimum Data Set (MDS- a standardized assessment tool that measures health status in nursing home residents) dated 2/07/24, Section C (Cognitive Patterns) C0500 indicated that Resident R6's Brief Interview for Mental Status (BIMS- 15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) score was seven (moderately impaired cognition). Observation on 4/09/24, at 9:15 a.m. revealed Resident R6 sitting in his/her wheelchair on a mechanical lift sling. Interview at that time with Resident R6 confirmed that sometimes there is only one helper using the lift. Resident R11's clinical record revealed an admission date of 11/30/23, with diagnoses that included anaplasmosis (illness caused by bacteria that's spread by ticks and often causes lameness, joint pain, fever, lethargy, and lack of appetite), irregular heartbeat, heart failure, kidney failure, and muscle weakness. Resident R11's clinical record revealed a physician's order dated 1/29/24, to transfer with a full mechanical lift and assistance of two. A current care plan entitled impaired mobility included to use a full mechanical lift with the assistance of two to get out of bed, and assist of two and a sit-to-stand lift when out of bed. The 5-Day MDS dated [DATE], Section C0500 indicated Resident R11's BIMS score was 15 (intact cognition). Observation on 4/09/24, at 10:50 a.m. revealed Resident R11 sitting in his/her wheelchair on a mechanical lift sling. Interview at that time with Resident R11 confirmed that sometimes there is only one person helping him/her in the lift. Resident R16's clinical record revealed an admission date of 7/01/21, with diagnoses that included heart disease, high blood pressure, anxiety, and dysthymic disorder (milder, but long-lasting form (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 3 of 9 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 04/10/2024 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 0684 of depression). Level of Harm - Minimal harm or potential for actual harm Resident R16's clinical record revealed a physician's order dated 3/14/22, to transfer with a full mechanical lift and assistance of two. A current care plan entitled falls included to use a full mechanical lift with the assistance of two to transfer. A quarterly MDS dated [DATE], Section C0500 indicated Resident R11's BIMS score was 13 (intact cognition). Residents Affected - Some Observation on 4/09/24, at 11:53 a.m. revealed Resident R16 sitting in his/her chair on a mechanical lift sling. Interview at that time with Resident R16 confirmed that sometimes there is only one person helping him/her in the lift. Resident R17's clinical record revealed an admission date of 4/28/22, with diagnoses that included chronic inflammatory demyelinating polyneuropathy (CIDP- is a neurological disorder that involves progressive weakness and reduced senses in the arms and legs), malnutrition, heart valve block, blood clots in the legs, and arthritis. Resident R17's clinical record revealed a physician's order dated 6/17/22, transfer with a full mechanical lift and assistance of two. A current care plan entitled falls included to use a full mechanical lift with the assistance of two to transfer. An annual MDS dated [DATE], Section C0500 indicated Resident R11's BIMS score was 13 (intact cognition). Observation on 4/10/24, at 10:15 a.m. revealed Resident R17 sitting in his/her chair on a mechanical lift sling. Interview at that time with Resident R17 confirmed that sometimes there is only one staff operating the mechanical lift. Resident R10's clinical record revealed an admission date of 11/17/22, with diagnoses that included dislocated right hip, multiple sclerosis (disease that impacts the brain, spinal cord, and optic nerves, which make up the central nervous system and controls everything we do), and paraplegia (specific pattern of where you can't deliberately control or move your muscles of your legs). Resident R10's clinical record revealed a physician's order dated 11/18/22, transfer with a mechanical lift. A current care plan entitled impaired mobility included to use a full mechanical lift with the assistance of two to transfer. A quarterly MDS dated [DATE], Section C0500 indicated Resident R10's BIMS score was 15 (intact cognition). Observation on 4/10/24, at 12:30 p.m. revealed Resident R10 sitting in his/her wheelchair on a mechanical lift sling. Interview at that time with Resident R10 confirmed that he/she is transferred many times with one staff using the lift, and unless he/she wants to wait hours to get out of bed, it is necessary, and that staffing is a concern of his/hers for this reason. Interviews on 4/09/24, at 9:30 a.m. with Employees E1 and E2 confirmed that sometimes they use the mechanical lifts by themselves due to having to hunt someone down to help them. Interview on 4/10/24, at 12:55 p.m. with the Director of Nursing confirmed that all mechanical lift transfers should be done with two staff members. 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 4 of 9 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 04/10/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and staff interviews, it was determined that the facility failed to implement sufficient safety precautions to prevent a resident with a history of suicide ideations from attempting to inflict self-harm for one of two residents reviewed with a history of suicide ideation and resulted in an Immediate Jeopardy situation (Resident R3). Findings include: Resident R3's clinical record revealed an admission date of 12/28/23, with diagnoses that included Bipolar Disorder with severe psychotic features (condition characterized by the presence of either delusions or hallucinations or both), major depressive disorder, generalized anxiety disorder, Agoraphobia with panic disorder (phobic-anxious syndrome where patients avoid situations or places in which they fear being embarrassed, or being unable to escape or get help if a panic attack occurs), and post-traumatic stress disorder (mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). Resident R3's hospital discharge records dated 12/28/23, revealed that the reason for his/her admission to the hospital was due to making suicidal statements, and having delusional thoughts. Hospital records from 3/27/24, revealed that the reason for his/her admission to the hospital was due to wrapping his/her call bell cord around his/her neck, and having delusional thoughts. Resident R3's physician's orders revealed; an order dated 3/14/24, to keep a tap bell within reach at all times, and 3/28/24, to keep a tap bell at bedside. Resident R3's current care plans revealed: -Potential for falls initiated 12/29/23, indicated for his/her call bell to be within reach at all times when in room. -Impaired mobility initiated 12/29/23, indicated to keep his/her call bell in reach and remind Resident R3 not to transfer without assistance. -Potential for infection initiated 12/29/23, indicated to keep his/her call bell within reach when in room. -Physical behaviors related to bipolar disorder initiated 3/28/24, indicated for a tap bell at bedside. -Self-care deficits initiated 12/29/23, and updated on 3/14/24, for a tap bell within reach at all times. Resident R3's clinical record revealed: -12/28/23, an admission note: resident spoke to himself/herself the whole way but not to others, diagnosis of suicidal ideation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 5 of 9 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 04/10/2024 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 0689 -12/29/23, 1/03/24, repetitive chanting Level of Harm - Immediate jeopardy to resident health or safety -1/02/24, practitioner admission assessment note: suicidal ideations, waving a gun at police, history of overdose, hallucinations, delusions, paranoia, combative with hospital staff. Residents Affected - Few -1/03/24, readmission practitioner note stated the hospital stay was complicated by behaviors, hallucinations. -1/09/24, psychotropic evaluation: frequent delusions that are harmful to self or others. -1/13/24- throwing dishes, silverware, and cup, told staff he/she was fighting with the devil. -1/18/24- chanting about the devil chasing him/her, disturbing other residents. -1/21/24- chanting, reported the devil was after him/her, throwing drink, swearing in the dining room. -1/25/24- yelling out Hallelujah, hallelujah, praise, praise, praise the lord repeatedly. Throwing pillows at the devil, the devil has a hold on his/her heart, auditory hallucinations, telling staff he/she is God, St. [NAME] is God, the guy shuffling in the hall is the one true God. -2/02/24- calling out for staff to pray with him/her. -2/02/24- practitioner note stated the resident has daily struggles with hallucinations, voices acute concerns about the devil and his presence in the facility. -2/26/24- voices telling resident to get out of bed, referenced battling with the devil, reported being frightened. -2/27/24- practitioner note stated the resident reported constantly hearing voices from the devil. -2/29/24- practitioner note reported that the resident confirmed he/she knows the voices are just hallucinations but can't ignore them and is getting depressed they aren't improving. -3/02/24- threw his/her water cups and cans of soda at roommate. -3/05/24- care plan note indicated the resident continues to experience hallucinations/delusions but is more aware of them. -3/07/24- fearful, chanting for staff, requesting they stay because the devil is after him/her. -3/08/24- yelling, throwing objects (cell phone, water pitcher, tv remote). In dining room chanting and reported the devil was after him/her again. -3/18/24- referral made to inpatient psych center. -3/19/24, 3:24 a.m. - yelling, disruptive, chanting and throwing items from bedside. -3/19/24, 3:28 a.m.- found with call bell wrapped around his/her neck three times, chanting, call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 6 of 9 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 04/10/2024 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 0689 bell removed, and 15-minute checks started. Level of Harm - Immediate jeopardy to resident health or safety -3/19/24, 3:33 a.m.- call made to Crisis. -3/19/24, 3:52 a.m. found with call bell cord around his/her neck again, confirmed trying to hurt themselves, and sent for evaluation. Residents Affected - Few -3/20/24- admitted to inpatient psych center. -3/28/24, 12:01 a.m.- found with call bell around his/her neck, taken out of reach and tap bell provided, 15 minutes later had blankets around his/her head. -3/28/24, 12:44 a.m.- found call bell around his/her neck, call bell removed and tap bell provided, chanting, and hollering out, found again with bed control cord around neck and placed out of reach by staff. -3/29/24- Practitioner readmission note indicated the resident was sent to hospital on 3/19/24, after multiple attempts to wrap a call bell cord around the neck which were felt to be acts of suicide, returned to facility 3/27/24. -3/31/24, 6:27 a.m. found with call bell wrapped around neck, removed, resident stated that the devil was after him/her, order to send to the hospital. -3/31/24, 6:53 a.m. progress note indicated that resident began with behaviors between 3:30 and 4:00 a.m., and eventually found with the call bell wrapped around his/her neck and that the call bell was last seen laying along the pillow a few minutes prior. -3/31/24, 7:06 a.m. when emergency services arrived the resident had the call bell wrapped around his/her wrist. Prior to Resident R3's transfer to the hospital on 3/31/24, his/her clinical record revealed 47 departmental assessment notes that indicated there were no safety concerns and that the call light was within reach. In an interview on 4/09/24, at 12:36 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that Resident R3 should not have had access to his/her call light cord and that the facility should have taken more safety measures to prevent him/her from attempting self-harm. The facility failed to implement sufficient safety measures to prevent residents with a history of suicidal attempts/ideations from attempting self-harm, putting a resident with a history of suicide attempts/ideations at risk and causing an Immediate Jeopardy. The NHA and DON were notified of the Immediate Jeopardy (IJ) situation on April 9, 2024, at 12:39 p.m. An Immediate Action Plan was requested and the IJ template was provided to the NHA. The Immediate Action Plan was provided by the NHA and DON on April 9, 2024, at 3:38 p.m. which was accepted at 3:43 p.m. The plan included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 7 of 9 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 04/10/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety 1. Educate all direct care staff on signs and symptoms of suicidal ideations and appropriate action to take regarding resident safety. 2. Resident on return to facility will not have a corded call bell. She will be given a tap bell and screened daily by nursing staff for signs or symptoms of increasing depression or suicidal ideations for a duration of one week, then every other day for one week, then weekly indefinitely. Residents Affected - Few 3. DON with LNAC will audit current resident records for histories of suicidal ideation or attempts by close of business on 4/9/24. 4. LNAC will update care plans of current residents to reflect these histories and include interventions, which will become standard for any resident entering with history of suicidal ideation or attempts by close of business on 4/9/24. 5. Administrator and DON will educate RNAC, LNAC, and Social Worker 4/10/24 on standard care plan interventions related to historical suicidal ideation or attempts. These will include ensuring there is no access to common suicidal methods and will be individualized based on resident history and current assessment. Beginning on 4/10/24 the Columbia Suicide Severity Rating Scale (CSSRS) will be administered by an RN on all new admissions. A licensed nurse (RN or LPN) will administer the CSSRS weekly, indefinitely, for those residents with a known suicidal ideation history. Residents scoring low risk with no history will require no follow up. Residents scoring low risk with a history of suicidal ideation will continue to be monitored and standard interventions in place with no additional referrals or notifications needed. Residents scoring moderate risk with or without a history of suicidal ideations or attempts will be referred for behavioral health consult and MD notified during daylight hours. Residents scoring high risk, with or without a history of suicidal ideations or attempts will immediately provide supervision until an evaluation has been completed and the resident deemed safe or sent to acute care for an evaluation. MD will be notified as soon as possible for further review and recommendations. 6. Educate all direct care staff on each resident's individual care plan needs regarding suicidal ideations. 7. All Items in this action plan will be reviewed at quarterly QAPI. On April 10, 2024, at 3:43 p.m. the Immediate Jeopardy was lifted after ensuring the Immediate Action Plan had been implemented. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(d)(e)(1) Management 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 8 of 9 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 04/10/2024 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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on review of facility records and job descriptions, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that proper supervision and self-harm prevention interventions were effectively implemented in the facility. Residents Affected - Few Findings include: The job description for the NHA revealed that the NHA is responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting, and physical management of the facility, residents, and equipment in such a manner that the purpose of the facility will be established and maintained in accordance with current Federal, State, and Local standards, guidelines, regulation, and established policies. The job description for the DON specified that the primary purpose of the job position is to plan, organize, develop, and direct the overall operation of the Nursing Services Department in accordance with current Federal, State, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. Based on the findings in this report that identified the facility failed to consistently supervise and maintain all safety interventions to prevent self-harm for their residents, the NHA and the DON failed to fulfill their essential job duties to ensure that the Federal and State guidelines and Regulations were followed. Refer to F689 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 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 9 of 9