Health inspection·January 9, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and staff interview, it was determined that the facility failed to maintain a clean homelike environment for one of five units (Memory Lane). Residents Affected - Few Findings include: Observation on Memory Lane on 1/06/25, at 3:00 p.m. revealed Resident R70 lying in bed with his/her eyes closed. Resident R70's wheelchair was at bedside and noted to have a dry, white, food-like substance on the seat cushion and on his/her bilateral arm rest. Observation on Memory Lane on 1/07/25, at 9:39 a.m. revealed Resident R1 lying in bed watching television. Resident R1's wheelchair was noted to be in the hallway and was observed to have a dried tan substance running down the left side of his/her seat cushion and the left side of his /her wheelchair base. Observation on Memory Lane on 1/07/25, at 1:00 p.m. revealed Resident R70 sitting in his /her wheelchair in the resident lounge. Resident R70's wheelchair cushion was not visible at time of observation, but bilateral arm rest continued to have a dry white food-like substance present. Observation at this time, also revealed Resident R1 sitting in his/her wheelchair watching television with the dried tan substance still present on the left side of his/her seat cushion and the left side of his/her wheelchair base. During an interview on 1/07/25, at 1:00 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Residents R1 and R70's wheelchairs were unclean with dried debris noted. LPN Employee E1 stated the wheelchairs should not be dirty. 28 Pa. Code 201.18(b)(1) Management FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 2 of 13 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 01/09/2025 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records and staff interviews, it was determined that the facility failed to accurately code the Minimum Data Set (MDS - periodic assessment of resident care needs) for two of 22 residents reviewed (Residents R1 and R46). Residents Affected - Few Findings include: Resident R1's clinical record revealed an admission date of 11/04/96, with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube to provide feedings through when a person cannot take food or liquids by mouth), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs often times including the torso and face. Individuals experience muscle stiffness, uncontrolled muscle contractions, joint inflexibility and difficulty communicating). Resident R1's clinical record revealed a physician's order dated 5/20/24, indicating he/she receives Jevity 1.5 (a high calorie, fiber fortified liquid supplement for tube feedings) at 50 milliliters (ml) per hours continuously. An MDS with an Assessment Reference Date (ARD) of 11/11/24, under section Swallowing / Nutritional Status Section K0520 Nutritional Approaches indicated to check all of the following nutritional approaches that apply while a resident of the facility and within the last seven days. Section K0520B Feeding Tube (examples - nasogastric or abdominal [Peg]) was not checked for Resident R1 to identify they were receiving a feeding tube while a resident of the facility and within the last seven days. During an interview 1/09/25, at 9:34 a.m. the Director of Nursing confirmed that Resident R1's MDS with an ARD of 11/11/24, Section K0520B was coded inaccurately and should have been checked for having a feeding tube while a resident at the facility and within the last seven days. Resident R46's clinical record revealed an admission date of 7/07/20, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), and diabetes (a health condition that caused by the body's inability to produce enough insulin). Resident R46's clinical record revealed no evidence of weight loss or weight gain in the last month or six months. An MDS with an ARD of 7/12/24, under section Swallowing/Nutritional Status section K0300 Weight loss revealed for loss of 5% in the last month or loss of 10% or more in last 6 months was coded as Yes, not on prescribed weight loss regimen. An MDS with an ARD of 9/10/24, under section Swallowing/Nutritional Status section K0300 Weight loss revealed for loss of 5% in the last month or loss of 10% or more in last 6 months was coded as Yes, not on prescribed weight loss regimen. An MDS with an ARD of 12/09/24, under section Swallowing/Nutritional Status section K0300 Weight loss revealed for loss of 5% in the last month or loss of 10% or more in last 6 months was coded as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 3 of 13 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 01/09/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Yes, not on prescribed weight loss regimen and section K0310 Weight gain revealed for gain of 5% in the last month or gain of 10% or more in last 6 months was coded as Yes, not on physician prescribed weight gain regimen. During an interview on 1/08/25, at 1:32 p.m. with Dietary Technician Employee E9, he/she verified that Resident R46 did not have a weight gain or loss. He/she also confirmed that Section K0300 of the MDS's dated 7/12/24, and 9/10/24, was incorrectly coded for Resident R46 regarding weight loss and Section's

K0300 and K0310 of the MDS on 12/09/24, was incorrectly coded for Resident R46 regarding weight loss and gain. 28 Pa. Code 211.5(f)(iv)(ix) Medical records 28 Pa. Code 201.14 (a) Responsibility of Licensee FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 4 of 13 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 01/09/2025 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 Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 22 residents reviewed (Residents R46 and R56). Residents Affected - Few Findings include: Review of Resident R46's clinical record revealed an admission date of 7/7/20, with diagnoses that included Alzheimer's Disease (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), and diabetes (a health condition that caused by the body's inability to produce enough insulin). Review of Resident R46's physician's orders revealed an order dated 11/17/24, for staff to turn and reposition every two hours. Review of Resident R46's care plans revealed a care plan for impaired mobility with an intervention to turn and reposition every two hours. Observations on 1/07/25, at 9:25 a.m., 11:20 a.m., 12:30 p.m., 12:50 p.m., 2:00 p.m., at 3:08 p.m., and at 3:15 p.m. all revealed Resident R46 was in his/her bed positioned on his/her buttocks. During an interview on 1/07/25, at 3:16 p.m. Licensed Practical Nurse (LPN) Employee E8 confirmed that Resident R46 has a physician's order to be turned and repositioned every two hours. He/she also confirmed that Resident R46 should be repositioned every two hours. Review of Resident R56's clinical record revealed an admission date of 12/27/23, with diagnoses that included Dementia (a disease that affects short term memory and the ability to think logically), and hypertension (high blood pressure). Review of Resident R56's physician's orders revealed an order dated 9/26/24, for pillow boots to bilateral feet at all times except care. Review of Resident R56's care plans revealed a care plan for risk for skin breakdown with the intervention of pillow boots to bilateral feet at all times except care. Observations on 1/06/25, at 2:10 p.m. revealed Resident R56 was sitting in his/her wheelchair in the lounge with no pillow boots on bilateral feet and his/her pillow boots were lying on their bedside stand. Observations on 1/07/25, at 9:23 a.m., 10:10 a.m., and 11:20 a.m. all revealed Resident R56 was sitting in his/her wheelchair in the lounge with no pillow boots on bilateral feet and his/her pillow boots lying on their bed. Observations on 1/08/25, at 11:40 a.m. revealed Resident R56 was sitting in his/her wheelchair in the lounge with no pillow boots on bilateral feet and his/her pillow boots lying on their nightstand. During an interview on 1/08/25, at 11:45 a.m. LPN Employee E10 confirmed that Resident R56 was sitting in the lounge with no pillow boots on his/her bilateral feet. He/she also confirmed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 5 of 13 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 01/09/2025 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 Resident R56's pillow boots should be on his/her bilateral feet per physician's orders. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 6 of 13 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 01/09/2025 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, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders and failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for two of two residents reviewed for respiratory services (Residents R51 and R1). Residents Affected - Few Findings include: A facility policy dated 6/11/24, entitled Oxygen Administration indicated Verify that there is a physician's order for this procedure. Review the physician's order . for oxygen administration. Resident R51's clinical record revealed an admission date of 5/02/23, with diagnoses that included chronic obstructive pulmonary disease (COPD - condition when your lungs do not have adequate air flow), and peripheral vascular disease (PVD - a condition when there is restricted blood flow to the limb, usually legs). Resident R51's Care Plan revealed a care plan for altered cardiac output and respiratory function with an intervention of oxygen at 3 lpm (liters per minute) via nasal cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen), Licensed Nurse to ensure oxygen is in place, and being administered at ordered rate. Resident R51's clinical record revealed a physician's order dated 10/27/24, for oxygen at 3 lpm via nasal cannula for hypoxia (low oxygen levels). Further review revealed a physician's order to clean oxygen concentrator filter with hot soapy water weekly on Saturday. Observation on 1/07/25, at 9:50 a.m. revealed Resident R51 lying on his/her bed with supplemental oxygen in place and the oxygen concentrator liter flow set at 4 lpm. Further observation of the concentrator filers to bilateral sides of the oxygen concentrator revealed a large amount of a gray fluffy substance covering bilateral filters. During an interview on 1/07/25, at 10:10 a.m. Licensed Practical Nurse (LPN) Employee E8 confirmed that Resident R51's oxygen concentrator was on and set at 4 lpm and was not in accordance with the physician's order dated 10/27/24, for oxygen at 3 lpm. LPN Employee E1 also confirmed that the filters to the bilateral sides of the oxygen concentrator were covered in a gray fluffy substance and the filters should be clean per physician orders. Resident R1's clinical record revealed an admission date of 11/04/96, with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube to provide feedings through when a person cannot take food or liquids by mouth), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs often times including the torso and face. Individuals experience muscle stiffness, uncontrolled muscle contractions, joint inflexibility and difficulty communicating). Resident R1's clinical record revealed a physician's order dated 5/20/24, for oxygen at 4 lpm via trach mask (mask that covers the tracheostomy site to administer oxygen). Further review of physician's orders revealed an order dated 5/20/24, to clean oxygen concentrator filter with hot soapy water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 7 of 13 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 01/09/2025 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 weekly with tubing change on 11-7 shift weekly on Saturday. Level of Harm - Minimal harm or potential for actual harm Observations on 1/06/25, at 12:53 p.m. and 1:55 p.m. revealed Resident R1's oxygen concentrator had a filter on the back of the concentrator that contained a gray dusty substance. Residents Affected - Few During an interview on 1/06/25, at 1:55 p.m. Registered Nurse Employee E2 confirmed that the oxygen concentrator filter contained a gray dusty substance and should not, but was unsure as to how often or when they are to be cleaned. 28 Pa. Code 211.10(c) 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 8 of 13 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 01/09/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to label a multi-dose insulin (medication to treat elevated blood sugar levels) vial with the date it was opened, in one of five medication carts (Memory Lane) and failed to ensure medications for self-administration were properly secured for one of 22 residents reviewed (Resident R22). Findings include: Review of the facility policy entitled Vials and Ampules of Injectable Medications dated 6/11/24, indicated vials and ampules medications are used in accordance with the manufacturer's recommendations or the providers pharmacy's directions for storage, use, and disposal. It also indicated that at a minimum, the date opened must be recorded. Review of the facility policy entitled Self-Administration of Medications dated 6/11/24, indicated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of the residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. Observation on 1/07/25, at 8:30 a.m. revealed the Memory Lane medication cart contained an opened undated multi-dose Lantus insulin vial and the manufacturer's packaging was labeled to discard within 28 days of opening. During an interview at that time, Licensed Practical Nurse (LPN) Employee E1 confirmed that multi-dose vials/containers of medication are to be dated upon opening to ensure that staff discard them in a timely manner and the medication is not to be utilized past the medication expiration. Resident R22's clinical record revealed an admission date of 6/16/16, with diagnoses that included diverticulitis (an inflammation or infection in the digestive tract), type II diabetes (condition where the pancreas does not make enough insulin), and hypothyroidism (condition where the thyroid gland does not produce enough thyroid hormone). Resident R22's physician's orders dated 3/04/24, revealed an order indicating Resident R22 may self-administer medications. Medications must be returned to nurse in between administration times for safe keeping. Observation of Resident R22's room on 1/07/25, at approximately 10:00 a.m. revealed a plastic storage bin filled with multiple medications sitting on the resident's bedside tray table. At that time, Resident R22 stated he/she self-administers his/her medications and that the medications remain on his/her bedside tray table all day. During an interview on 1/07/25, at approximately 10:12 a.m. LPN Employee E6 confirmed that Resident R22's medications are given to him/her in a plastic storage bin and are left in Resident R22's room throughout the day, unsecured. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 9 of 13 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 01/09/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm During an interview on 1/08/25, at approximately 9:00 a.m. LPN Employee E7 confirmed that he/she would take Resident R22's medications to his/her room in the morning and the medications would remain unsecured in Resident R22's room until approximately 5:00 p.m. 28 Pa. Code 201.18(b)(1) Management Residents Affected - Few 28 Pa. Code 211.9(a)(1) Pharmacy services 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 10 of 13 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 01/09/2025 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 maintain complete and accurate documentation for two of 22 residents reviewed (Residents R1 and R37). Findings include: Facility policy entitled Documentation dated 6/11/24, indicated to document information as soon as possible to ensure accuracy of the information and to reflect ongoing care and to document only care, treatment, and medication that have actually been provided or administered. Facility policy entitled Enteral Tube Feeding Via Continuous Pump dated 6/11/24, indicated the person performing the procedure should record the amount and type of enteral feeding and the average fluid intake per day. Resident R1's clinical record revealed an admission date of 11/04/96, with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube to provide feedings through when a person cannot take food or liquids by mouth), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs often times including the torso and face. Individuals experience muscle stiffness, uncontrolled muscle contractions, joint inflexibility and difficulty communicating). Resident R1's clinical record revealed a physician's order dated 5/24/24, for flush enteral feeding tube with 150 milliliter (ml) of water every four hours (300 ml of water per shift plus more depending on medication administration) and with 50 ml of water before and after medication administration; a physician's order dated 5/20/24, for Jevity 1.5 (a high calorie, fiber fortified liquid supplement for tube feedings) at 50 ml per hour continuous via gastric tube (a total of 400 ml per shift and 1200 ml total of formula in a twenty-four hour period); and a physician's order dated 5/20/24, to document the amount of formula and water provided every eight hours - total intake every twenty-four hours. Review of documentation of water flushes for Resident R1 from 12/10/24, through 1/07/25, under staff tasks revealed Resident R1 received less than the ordered 300 ml of water flush per shift (not counting medication flushes) one time on day shift, one time on evening shift, and three times on overnight shift. Documentation also revealed that facility lacked any evidence of water flushes one time on day shift, eight times on evening shift, and three times on overnight shift. Review of documentation of formula intake for Resident R1 from 12/10/24, through 1/07/25, under staff tasks revealed Resident R1 received less than the ordered 400 ml of formula per shift four times on day shift, ten times on evening shift, and eleven times on overnight shift; and Resident R1 received more than the ordered 400 ml of formula per shift eleven times on day shift, seven times on evening shift, and eleven times on overnight shift. Documentation also revealed that facility lacked any evidence of formula being provided one time on day shift, seven times on evening shift, and three times on overnight shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 11 of 13 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 01/09/2025 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 During an interview on 1/08/25, at 2:49 p.m. the Director of Nursing confirmed that Resident R1's clinical record contained incomplete and inaccurate documentation related to his / her tube feeding formula and water flushes. Resident R37's clinical record revealed an admission date of 5/30/24, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), high blood pressure, and urinary tract infection (UTI). Resident R37's clinical record revealed a physician's order dated 12/15/24, for Keflex (antibiotic) 500 milligrams by mouth every twelve hours for UTI for seven days. Review of the Medication Administration Record (MAR) revealed the first dose was administered at 9:00 a.m. on 12/15/24, and the last dose was administered at 9:00 p.m. on 12/21/24. Resident R37's clinical record progress notes dated / timed for 12/21/24, at 10:22 p.m., 12/21/24 at 11:36 p.m., 12/22/24, at 2:25 p.m., 12/22/24, at 8:56 p.m., 12/23/24, at 11:38 a.m., 12/23/24, at 6:54 p.m., 12/24/24, at 5:11 a.m., 12/24/24, at 10:43 a.m., 12/24/24, at 11:09 p.m., 12/25/2024, at 12:10 a.m., 12/25/24, at 9:54 p.m., 12/25/23, at 11:07 p.m., 12/26/24, at 11:02 a.m., and 12/26/24, at 6:49 p.m. indicated Resident R37 was receiving Keflex for a UTI when the last dose was received at 9:00 p.m. on 12/21/24. During an interview on 1/08/25, at 12:23 p.m. the Director of Nursing confirmed that Resident R37's clinical record contained inaccurate documentation related to him/her receiving Keflex for a UTI. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 If continuation sheet Page 12 of 13 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 01/09/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy and clinical records, observation, and staff interview, it was determined that the facility failed to follow acceptable infection control practices regarding enhanced barrier precautions (EBP) during observation of tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing) care for one of three residents observed for care requiring EBP (Resident R1). Residents Affected - Few Findings include: A facility policy entitled Enhanced Barrier Precautions dated 6/11/24, indicated that Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms to residents. The policy further stated that high contact resident care activities that require the use of gown and gloves for EBP's included devise care or use such as tracheostomies and that face protection may be used if there is also a risk of splash or spray. Resident R1's clinical record revealed an admission date of 11/04/96, with diagnoses that included tracheostomy (a hole made through the front of the neck and into the windpipe [trachea] where a tube is placed to keep the hole open for breathing), gastrostomy tube (a surgical incision is made through the abdomen wall and into the stomach to insert a tube to provide feedings through when a person cannot take food or liquids by mouth), and spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs often times including the torso and face. Individuals experience muscle stiffness, uncontrolled muscle contractions, joint inflexibility and difficulty communicating). Resident R1's clinical record revealed a physician's order dated 10/24/24, that identified for the use of Enhanced Barrier Precautions for Tracheostomy. Observation of tracheostomy care on 1/06/25, at 1:50 p.m. revealed signage on Resident R1's door identifying EBP. Personal protective equipment (PPE) was readily available outside Resident R1's door including goggles, surgical mask, gloves, and gowns. Registered Nurse (RN) Employee E2 had a surgical mask on, but pulled down below his/her nose, and gloves, and failed to DON (put on) required proper personal protective equipment (PPE) by not wearing a gown during tracheostomy care for Resident R1. During an interview on 1/06/25, at 1:56 p.m. RN Employee E2 confirmed he/she did not wear a gown as required stating that if the resident does not have an infection or COVID, he/she does not wear a gown and the additional PPE was not needed if the resident was well. 28 Pa. Code 211.10(c) 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 13 of 13