Penn Highlands Jefferson Manor

In the surveyor’s words

From the most serious findings on record at Penn Highlands Jefferson Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 10, 2024

  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 admitted [DATE], 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… […]

• Actual harm, isolatedF600Feb 3, 2026

  Based on review of facility policy and clinical and facility records and staff interview, it was determined that the facility failed to ensure Resident R1 was free of neglect during care, which resulted in actual harm of a left hip fracture requiring surgical repair for one resident (Resident R1). Findings include: Review of a current facility policy entitled, Abuse-Neglect and Exploitation revealed the following Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Neglect occurs on an individual basis when a resident receives a lack of care in one or more areas (e.g. […]

• Actual harm, isolatedF689Feb 3, 2026

  Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall which resulted in the actual harm of a left hip fracture requiring surgical repair for one resident (Resident R1). Findings include: Resident R1's clinical record revealed an admission date of 1/8/24, with diagnoses that included dementia, anxiety, colon cancer and osteoporosis. Resident's R1's Minimum Data Set (MDS - periodic assessment of resident care needs), Section GG0170 Functional abilities Mobility dated 6/27/25, revealed Resident R1 was dependent (helper does ALL of the effort. Resident does none of the effort to complete the activity. […]

• No harm, potential for more than minimal, widespreadF725Mar 8, 2024

  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. […]

• No harm, potential for more than minimal, patternF684Apr 10, 2024

  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). 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. […]