Health inspection·August 15, 2024

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on review of Title 49. Professional and Vocational Standards, facility policy, and clinical records and staff interview, it was determined that the facility failed to assure that a Registered Nurse (RN) conducted initial and/or follow-up resident wound assessments for two of two residents reviewed with wounds (Residents R14 and R15). Findings include: Review of the Title 49. Professional and Vocational Standards, Department of State Chapter 21, State Board of Nursing, dated 5/25/24, indicated that under Responsibilities of the RN, 21.22, General Functions. (a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible, and (b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered. The 21.141 Definitions, Practice of practical nursing revealed The performance of selected nursing acts in the care of the ill, injured or infirm under the direction of a licensed professional nurse, a licensed physician or a licensed dentist, which do not require the specialized skill, judgement and knowledge required in professional nursing. The 21.145 Functions of the LPN [Licensed Practical Nurse], (a) . The LPN participates in the planning, implementation and evaluation of nursing care using the focused assessment in settings where nursing takes place. A facility policy dated 6/11/24, entitled Pressure Ulcer Assessment / Prevention indicated The Wound Nurse/RN will complete weekly skin rounds and measure pressure ulcers, arterial / vascular ulcers, and surgical incisions. The findings will be documented in the electronic medical record. Resident R14's clinical record revealed an admission date of 6/16/16, with diagnoses that included diabetes (a chronic condition that affects the way the body processed blood sugar), diverticulitis (inflammation of pouches in the wall of the large intestines, and venous thrombosis (blood clot in the deep vein most commonly located in the leg or pelvis). Resident R14's clinical record progress notes revealed that on 7/11/24, staff observed an open area to Resident R14's coccyx. Progress note dated 7/12/24, revealed an assessment of the coccyx wound that was completed by Licensed Practical Nurse (LPN) Employee E1. Progress notes dated 7/22/24, and 8/05/24, revealed an assessment of the coccyx wound that was completed by LPN Employee E2. Progress note dated 8/12/24, revealed an assessment of the coccyx wound that was completed by LPN Employee E3. There was no evidence that the comprehensive wound assessment was completed by an RN on 7/12/24, 7/22/24, 8/05/24, or 8/12/24. Resident R15's clinical record revealed an admission date of 2/04/22, with diagnoses that included dementia (a condition that affects a persons memory, thinking, and behaviors), osteoarthritis (degenerative joint disease that results from the breakdown of joint cartilage and bones), and peripheral vascular disease (disorder of the blood vessels outside the heart that can affect the brain, legs, feet, and other organs). Resident R15's clinical record progress notes dated 6/07/24, 6/14/24, 6/21/24, 6/28/24, 7/05/24, 7/12/24, 7/29/24, 7/26/24, 8/02/24, and 8/09/24, revealed an assessment of the right hip wound that was completed by LPN Employee E1. Progress note dated 8/06/24, revealed an assessment of the right hip (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 2 of 3 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 08/15/2024 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 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wound that was completed by LPN Employee E2. Progress note dated 8/13/24, revealed an assessment of the right hip wound that was completed by LPN Employee E4. There was no evidence that the comprehensive wound assessment was completed by an RN on 6/07/24, 6/14/24, 6/21/24, 6/28/24, 7/05/24, 7/12/24, 7/29/24, 7/26/24, 8/02/24, 8/06/24, 8/09/24, or 8/13/24. During an interview on 8/14/24, at 1:27 p.m. the Nursing Home Administrator and Director of Nursing confirmed that wound assessments and documentation were conducted by an LPN, and not completed by an RN or completed with the oversight of an RN for Residents R14, and R15. 28 Pa. Code 201.18(e)(1) Management 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 3