Health inspection·December 18, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete month of November 2025, that his/her Sitagliptin 50 mg was not administered per physician order on 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Torsemide 20 mg give one tablet by mouth one time a day for cardiac heart failure. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Torsemide 20 mg was not administered per physician order on 11/10/25, and 12/13/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Rosuvastatin Calcium 20 mg give one tablet by mouth at bedtime for hyperlipidemia. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Rosuvastatin Calcium 20 mg was not administered per physician order on 11/21/25, and 12/01/25, and 12/16/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Gabapentin 100 mg give two capsules by mouth at bedtime for neuropathy. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Gabapentin 200 mg was not administered per physician order on 11/21/25, and 12/01/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Cyanocobalamin (form of vitamin B12) 1000 mcg give one tablet by mouth at one time a day for supplement. Resident R7's eMAR further revealed for the month of November 2025, that his/her Cyanocobalamin 1000 mcg was not administered per physician order on 11/10/25. During an interview on 12/17/25, at 12:20 p.m. the Director of Nursing (DON) confirmed the medications noted above were not administered per physician orders for Resident R7 during the months of November and December 2025, and the physician was not notified immediately regarding a medication that was unavailable to complete the physician orders for Resident R7. Resident R16's clinical record revealed an admission date of 12/1/23, with diagnoses that included Congestive Heart Failure (CHF - a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply causing blood and fluids collect in your lungs and legs over time), Atrial Fibrillation (A-Fib - irregular and often rapid heartbeat that can lead to stroke, heart failure, and other complications), and Left Heel Pressure Ulcer (damage to the skin and/or underlying tissue that usually occurs over a boney prominence). Review of Resident R16's clinical record revealed a physician's order dated for 9/26/25, for Left PRAFO (Pressure Relieving Ankle Foot Orthosis - a specialized orthotic device useful for individuals prone to heel skin breakdown, as it elevates the heel and can be adjusted for comfort and mobility). Observation on 12/15/25 at 4:00 p.m. revealed Resident R16 sleeping in bed with his/her PRAFO on the window ledge. Observation on 12/16/25, at 9:17 a.m. revealed Resident R16 laying in bed with his/her PRAFO on the window ledge. Observation on 12/17/25, at 11:42 a.m. revealed Resident R16 sitting in his/her wheelchair with his/her PRAFO on the window ledge. Observation on 12/17/25, at 1:10 p.m. revealed Resident R16 sleeping in bed with his/her PRAFO on the window ledge. Interview on 12/17/25, at 1:12 p.m. with Nurse Aide (NA) Employee E3 revealed he/she was told that Resident R16's son purchased it and puts it on Resident R16 in the evening when he comes in to visit and then he takes it off when he is ready to leave. NA Employee E3 stated he/she has never seen anything in the NA task instructing the staff on use of the PRAFO or to document use of the PRAFO. During an interview on 12/17/25, at 1:16 p.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that Resident R16's PRAFO was located on the window ledge and Resident R16 was not wearing it per physician orders. LPN Employee E2 also confirmed that there is a physician's order in place for the PRAFO to be worn at all times, but the clinical record lacked scheduling details, therefore it was not carried over into the NA tasks or Licensed Nurse Treatment Administration Record (TAR) to ensure staff were aware of the order and able to sign for usage. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services Event ID: Facility ID: 395626 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 395626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of facility policies and clinical records, and staff interview, it was determined that the facility failed to ensure medications were available from a pharmacy for timely medication administration to meet the needs of the resident for one of 20 residents reviewed (Resident R7). Findings include: Review of a facility policy Medication Administration dated 4/29/25, revealed all medications are to be administered only as prescribed, and only by licensed practical nursing staff. If a dose of regularly scheduled medication is withheld or refused, the nurse is to pick the correct reason for medication not being given in the eMAR (electronic medication administration record) in the EMR (electronic medication record) for the resident. The nurse is then responsible for notifying the RN Supervisor so that the family and physician can be made aware for further orders. Medications ordered must be available for use and all medications on hand must have a corresponding order. Review of a facility policy Preparation & General Guidelines dated 4/29/25, revealed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medications are administered within (60 minutes) of scheduled time, except before, with or after meal orders, which are administered (based on mealtimes). Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. Resident R7's clinical record revealed an admission date of 9/19/23, with diagnoses that included chronic diastolic congestive heart failure (when the heart's main pumping chamber becomes stiff and cannot fill properly to fill with enough blood, leading to fluid backup and heart failure), personal history of venous thrombosis (blood clot in a deep vein, DVT) and embolism (when a clot breaks off and travels throughout the veins typically to the heart and lungs), hyperlipidemia (high level of fats like cholesterol and triglycerides in the blood), and hypothyroidism (a condition when the thyroid gland doesn't produce enough thyroid hormone), and presence of artificial eye. Review of Resident R7's eMAR revealed a physician order with start date of 8/25/25, Xarelto (Rivaroxaban) give 20 mg (milligrams) by mouth one time a day for DVT. Resident R7's eMAR further revealed for the months of December and November 2025, that his/her Xarelto was not administered per physician order on 12/13/25, 11/01/25, and 11/10/25. A physician order with start date of 8/03/25, Levothyroxine Sodium (medication to treat thyroid disorder) 100 mcg (micrograms) give one tablet by mouth one time a day for low thyroid hormone. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Levothyroxine Sodium 100 MCG was not administered per physician order on 12/13/25, 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Metoprolol Succinate ER 24 Hour Sprinkle 50 mg give one capsule by mouth one time a day for hypertension. Resident R7's eMAR further revealed for the month of November and December 2025, that his/her Metoprolol Succinate extended release 24 Hour 50 mg was not administered per physician order on 11/01/25, and 11/06/25. Resident R7's eMAR revealed a physician order with start date of 8/06/25, Protonix (medication to treat acid reflux) delayed release 40 mg give one tablet by mouth two times a day. Resident R7's eMAR further revealed for the month of November 2025, that his/her Protonix delayed release 40 mg was not administered per physician order on 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Sitagliptin 50 mg give one tablet by mouth one time a day for diabetes. Resident R7's eMAR further revealed for the month of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395626 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 395626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete November 2025, that his/her Sitagliptin 50 mg was not administered per physician order on 11/01/25, and 11/10/25. Resident R7's eMAR further revealed for the month of November 2025, that his/her Protonix delayed release 40 mg was not administered per physician order on 11/01/25, and 11/10/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Torsemide 20 mg give one tablet by mouth one time a day for cardiac heart failure. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Torsemide 20 mg was not administered per physician order on 11/10/25, and 12/13/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Rosuvastatin Calcium 20 mg give one tablet by mouth at bedtime for hyperlipidemia. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Rosuvastatin Calcium 20 mg was not administered per physician order on 11/21/25, and 12/01/25, and 12/16/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Gabapentin 100 mg give two capsules by mouth at bedtime for neuropathy. Resident R7's eMAR further revealed for the months of November and December 2025, that his/her Gabapentin 200 mg was not administered per physician order on 11/21/25, and 12/01/25. Resident R7's eMAR revealed a physician order with start date of 8/03/25, Cyanocobalamin (form of vitamin B12) 1000 mcg give one tablet by mouth at one time a day for supplement. Resident R7's eMAR further revealed for the month of November 2025, that his/her Cyanocobalamin 1000 mcg was not administered per physician order on 11/10/25. During an interview on 12/17/25, at 12:20 p.m. the Director of Nursing confirmed the medications noted above were not available from a pharmacy for administration per physician orders for Resident R7 during the months of November and December 2025, and the physician and/or pharmacy was not notified immediately regarding a medication that was unavailable to complete the physician order timely for Resident R7. 28 Pa. Code 211.9(a)(d)(f)(4) Pharmacy services 28 Pa. Code 211.12(d)(1)(5) Nursing services Event ID: Facility ID: 395626 If continuation sheet Page 4 of 4