Pennsylvania Department of Health
PENN HIGHLANDS JEFFERSON MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PENN HIGHLANDS JEFFERSON MANOR
Inspection Results For:

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PENN HIGHLANDS JEFFERSON MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Complaint Survey completed on May 8, 2025, it was determined that Penn Highlands Jefferson Manor, was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 201.18(b)(2) LICENSURE Management.:

(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.

Observations:

Based on review of clinical records and staff interview, it was determined the facility failed to ensure the safeguard of personal belongings for one of one residents discharged from the facility (Closed Record Resident R1).

Findings include:

Review of Resident CR1's clinical record revealed an admission date of 1/13/25 and a discharge date of 1/16/25.

Review of Resident CR1's Personal Inventory Sheet identified one pair of eyeglasses documented during the admission process. The form identified a section of the form where a family member and staff member were required to sign that resident items were received and taken home upon discharge from the facility. That section of the form was incomplete and did not have the signature of a family member or a staff member who was present when the items were discharged with Resident CR1.

During an interview on 5/06/25, at approximately 12:45 p.m. the Nursing Home Administrator confirmed that there was no documented evidence that the one pair of eyeglasses was sent home with Resident CR1 upon discharge from the facility.

Plan of Correction - To be completed: 06/04/2025

The family of the deceased resident R1 has been contacted and offered replacement of the glasses. All residents in the facility will be reviewed to ensure their personal inventory sheet is updated. A notice has been sent to all existing residents in the facility with a detailed process of updating the belongings sheet. new admissions will have this process in their admission paperwork. All staff will be educated on the inventory belongings sheet being filled out properly upon admission and discharge. Facility Nursing Home Administrator, Director of Nursing or designee will audit all admissions and discharges to the facility for 30 days to ensure compliance is being maintained. After 30 days we will audit 3 admissions and 3 discharges monthly thereafter. This process will be reviewed in our Quality Assure Performance Improvement plan moving forward.

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