Health inspection·September 14, 2023

F 0575 Level of Harm - Potential for minimal harm Residents Affected - Many Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observations and staff interview, it was determined that the facility failed to display the Department of Health (DOH) Hotline (toll-free telephone number) number in a prominent/accessible location for residents, resident representatives, and other visitors to observe and access in the facility. Findings include: Observations throughout the facility on 9/13/23, at approximately 11:30 a.m. with Medical Records Employee E10 revealed that the DOH Hotline phone number was not posted for residents, resident representatives, and other visitors. During an interview on 9/14/23, at 10:30 a.m. the Nursing Home Administrator confirmed the facility failed to display the DOH Hotline phone number for residents, resident representatives, and other visitors. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e) (2.1) Management Page 1 of 15 395248 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, observations, and staff interviews it was determined that the facility failed to provide housekeeping services necessary to maintain a clean, homelike environment for one of 22 residents (Resident R71). Findings include: Review of a facility document provided on 9/13/23, entitled C-Hall Scrub Rooms indicated that Resident R71's room (room [ROOM NUMBER]) was assigned to be cleaned on Tuesdays, and indicated that the staff are to: clean the tops, sides, and front of nightstands, pull out bed and nightstands from walls, and sweep and mop the floors. Resident R71's clinical record revealed an admission date of 2/17/2020, with diagnoses that included sudden and long-term respiratory (breathing) failure, chronic obstructive pulmonary disease, (COPD- a group of diseases that cause airflow blockage and breathing-related problems), and cognitive communication deficit (inhibits or prevents one from performing normal mental processes such as talking, remembering things, problem-solving and safety awareness). Observations on 9/11/23, at 12:44 p.m. and on 9/12/23, at 9:40 a.m. of Resident R71's room revealed two white powder bottles and a nebulizer mask (mask that covers the mouth and nose usually held onto the face with an elastic band and used to treat respiratory disorders) on the floor between the bed and the nightstand. Observation on 9/13/23, at 11:38 a.m. of Resident R71's room revealed one white powder bottle and a nebulizer mask on the floor between the bed and the nightstand. During an interview on 9/13/23, at 11:44 a.m. the Director of Nursing confirmed the presence of the white powder bottle and nebulizer mask on the floor between the bed and nightstand. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(e) (2.1) Management 395248 Page 2 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm Based on review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual 2019 (RAI-assessment guide used to plan the provision of care for residents), clinical records and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set (MDS-federally mandated standardized assessment conducted at specific intervals to plan resident care) assessment accurately reflected the status for two of 22 residents reviewed (Residents R19 and R68) Residents Affected - Few Findings include: Review of the RAI manual instructions for Section M01030 Number of Venous and Arterial Ulcers identified to code the number currently present. Section B1000 and B1200 Vision and Corrective Lenses identified to code the ability to see in adquate light from 0- adquate, 1- impaired, 2-moderately impaired, 3- highly impaired and 4 - severly impaired and corrective lenses used 0- no 1 -yes Review of Resident R19's clinical record revealed an admission date of 12/13/22, with diagnoses that included heart disease, dementia, anxiety and high blood pressure. Review of Resident R19's Annual MDS with an Assessment Reference Date (ARD-last day of observation of the look back period) of 8/21/23, revealed that it was coded as having zero venous wounds. Clinical record documentation under skin/wound dated 8/08/23, and 8/15/23, both revealed the presence of two venous wounds one on the right lower leg and one on the right ankle. Resident R68's clinical record revealed an admission date of 12/03/21, with diagnoses that included heart conditions, high blood pressure and anxiety. Resident R68's Quarterly MDS with an ARD of 7/25/23, revealed under section B10000 Vision as 0 for Adequate vision and under section B1200. Corrective Lenses as 0 No Corrective Lenses used. Clinical record documentation dated 3/16/23, indicated impaired vision and that resident was not a surgical candidate. Previous MDS's for Resident R68 all indicated impaired vision and used corrective lenses. During an interview on 9/13/23, at 2:55 p.m. Registered Nurse Assessment Coordinator confirmed that Resident R19's 8/21/23 MDS, and Resident R68's 7/25/23 MDS, were both coded incorrectly. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.5(f) Clinical Records 395248 Page 3 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical records, and resident and staff interviews, it was determined that the facility failed to implement an effective discharge plan for one of 22 residents reviewed (Resident R40). Residents Affected - Few Findings include: Review of Resident R40's clinical record revealed an admission date of 10/12/20, with diagnoses including adult failure to thrive (a condition typically adults with multiple medical conditions involving loss of appetite weight loss, daily activity, and loss of interest in social activity). Long-term inflammation of the pancreas, esophageal varices (enlarged veins in the esophagus, the tube that connects the throat and stomach), depression, and anxiety. The clinical record also revealed a care plan dated 3/24/21, that indicated Resident R40 would like to move closer to another city when a bed would become available. Further review of Resident R40's clinical record revealed departmental progress notes dated: 12/14/22: indicated the facility spoke to Resident R40's family regarding the desire to transfer to another nursing home. 12/21/22: indicated that Resident R40's discharge plan was to transfer to a nursing home closer to family, and that his/her BIMs (Brief Interview for Mental Status- cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was a 15 (cognitively intact), he/she can make his/her needs known and is understood and can understand. 2/08/23: indicated that Resident R40 requested to be transferred to a nursing home closer to another town and he/she is agreeable to being assessed by therapy prior to discharge. 7/19/23: indicated that Resident R40 requested a referral be sent to another nursing home in the requested town 7/26/23: indicated that Resident R40 would like to move closer to his/her hometown and that his/her BIMs was an eight (moderately impaired), he/she can make his/her needs known and is understood and can understand. 8/03/23: indicated that Resident R40 would like to move closer to his/her hometown, and that his/her BIMs was an eight (moderately impaired), he/she can make his/her needs known and is understood and can understand. There was no evidence that the facility attempted to reach out to other nursing homes near Resident R40's hometown to make referrals on his/her behalf. During an interview on 9/11/23, at 1:05 p.m. Resident R40 confirmed that he/she has .been here for over two years and was originally only at this facility until a bed opened up in a nursing home closer to his/her hometown, and that he/she goes stir crazy, and does not receive visitors because his/her family lives two and a half to three hours away, and that he/she wished to be discharged to a nursing home closer to his/her home. 395248 Page 4 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0660 During an interview on 9/14/23, at 11:05 a.m. the Social Worker confirmed that there was no documentation to support discharge referral attempts to facilities closer to Resident R40's hometown. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.11(e) Resident care plan Residents Affected - Few 28 Pa. Code 201.14(a) Responsibility of licensee 395248 Page 5 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on review of facility policy, clinical records, and resident and staff interview, it was determined that the facility failed to ensure urinary catheter care was completed per physician orders for two residents reviewed (Residents R57 and R49) and failed to ensure adequate physician orders were in place for a urinary catheter for one resident reviewed (R49). Findings include: Review of the facility policy entitled Catheter Care-Routine, dated 8/3/2023, indicated to reduce the risk of infection, routine hygiene will be performed each day and as needed. Collection bag should be emptied as needed but at least every shift and document care performed in the electronic health record. Review of Resident R57's clinical record revealed an admission date of 6/30/2022, with diagnoses that included obstructive and reflux uropathy (urine blockage), hypertension (high blood pressure), type II diabetes, chronic kidney disease, and muscle weakness. Review of Resident R57's physician's orders dated 4/25/2023, revealed an order for foley catheter #16FR (French-size of the catheter) 10 cc (cubic centimeter) balloon to straight drain, check every shift. During an interview on 9/13/2023, at 10:00 a.m. R57 expressed he/she was concerned about how often his/her catheter bag is being emptied and care that was being performed. Review of R57's Treatment Administration Record for August 2023 and September 2023, completed by the Licensed Nurses revealed his/her urinary catheter was not checked and drained every shift per physician orders on 8/13/23, 8/18/23, 9/5/23, 9/8/23 and 9/10/23. Tasks that are completed by the Nursing Assistants (NA) for August 2023 and September 2023, revealed his/her urinary catheter was not checked and drained every shift per physician orders on 8/1/23, 8/3/23, 8/5/23, 8/7/23, 8/11/23, 8/13/23, 8/15/23, 8/17/23, 8/18/23, 8/21/23, 8/22/23, 8/24/23, 8/25/23, 8/30/23, 8/31/23, 9/5/23, 9/7/23, 9/9/23. 9/10/23, and 9/11/23. Review of Resident R49's clinical record revealed an admission date of 3/2/2023, with diagnoses that included cutaneous abscess of the perineum, cutaneous abscess of the buttock, heart failure, chronic kidney disease, and hyperglycemia (high blood sugar). Review of R49's Tasks for August 2023 and September 2023 revealed the only physician's order related to his/her foley catheter was for foley/suprapubic catheter: provide catheter care, every shift. Review of R49's physician order summary lacked evidence that adequate physician orders were in place for a urinary catheter, which would include but not limited to foley catheter and balloon size, foley catheter scheduled changes, foley catheter as needed changes due to soiling or dislodgement, draining the foley catheter collection bag, and foley catheter collection bag changes. Review of R49's Tasks that are completed by the NAs for August 2023 and September 2023, revealed his/her catheter care was not completed every shift per physician orders on 8/1/23, 8/2/23, 8/3/23, 8/4/23, 8/5/23, 8/7/23, 8/8/23, 8/9/23, 8/12/23, 8/13/23, 8/15/23, 8/17/23, 8/18/23, 8/21/23, 8/22/23, 395248 Page 6 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/23/23, 8/24/23, 8/26/23, 8/28/23, 8/29/23, 8/30/23,8/31/23, 9/4/23, 9/5/23, 9/6/23, 9/7/23, 9/9/23, 9/10/23, 9/11/23, and 9/12/23. During an interview on 9/13/2023, at 1:20 p.m. the Director of Nursing confirmed that the clinical records lacked evidence that catheter care was being completed per physician orders for residents R57 and R49 and that R49's clinical record lacked adequate urinary catheter orders. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(5) Nursing services 395248 Page 7 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to provide care and services to help prevent complications related to a gastrostomy tube (G-tube- a tube that is placed directly into the stomach through) for one of three residents with g-tubes (Resident R255). Findings include: Review of a facility policy entitled Verifying Tube Feed Placement dated 8/03/23, indicated that staff should always check the feeding tube placement prior to administering medications by aspiration of stomach contents (using a syringe to draw out stomach contents using a sucking motion). Review of Resident R255's clinical record revealed an admission date of 8/18/23, with diagnoses that included malnutrition, gastrostomy status, adult failure to thrive (state of decline that is multifactorial and includes weight loss, decreased appetite, poor nutrition, and inactivity). The clinical record also included a care plan entitled unintentional weight loss dated 8/19/23, that included check for tube placement and gastric contents per facility policy. Observation on 9/12/23, at 8:27 a.m. of medication administration revealed Licensed Practical Nurse (LPN) Employee E4 prepared medications to administer to Resident R255 through his/her g-tube and failed to verify placement prior to administering medications. During an interview at that time, LPN Employee E4 confirmed that he/she should have checked for tube placement before giving the medications. During an interview on 9/14/23, at 8:45 a.m. the Director of Nursing confirmed that LPN Employee E4 should have checked for g-tube placement prior to administering medications. 28 Pa. Code 211.12(d)(1)(5) Nursing services 395248 Page 8 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for the potential unauthorized access of medications on one of four medication carts (B Cart), failed to discard expired multi-dose vial Lantus insulin (long-acting insulin used to maintain healthy blood sugar levels) and label an opened Lispro insulin (fast-acting insulins used to control high blood sugar) pen with a resident's name and date opened on one of four medication carts (A Cart), and failed to label a multi-dose container of Tuberculin solution (used to test for the disease tuberculosis) with the date it was opened in one of two medication storage rooms (C/D Unit). Findings include: Review of a facility policy entitled, Storage of Medications dated 8/03/23, indicated that medication carts are locked when they are not attended, all expired medications will be removed from the active supply, and when the original seal is initially broken the container or vial will be dated and the expiration date of the container or vial will be 30 days from the opening. Observation on 9/11/23, between 11:55 a.m. and 11:58 a.m. revealed the B Cart in the B Unit hallway was unsecured and unattended. During an interview on 9/11/23, at 11:58 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that the B Cart was parked in the B unit hallway and was unsecured and unattended and that medication carts should be locked when not in view. Observation on 9/11/23, at 3:45 p.m. revealed that A Cart contained an opened multi-dose vial of Lantus dated as opened on 8/07/23, and an unsealed Lispro insulin pen that lacked a label containing a resident's name and an open date. During an interview at that time LPN Employee E2 confirmed that the multidose vial of Lantus was expired and should have been discarded on 9/07/23, and that there was no way to tell which resident was to receive the Lispro insulin or what date it was opened. Observation on 9/12/23, at 9:03 a.m. of medication storage room on the C/D Unit revealed an opened multi-dose vial of Tuberculin solution that lacked a date it was opened. During an interview at that time Registered Nurse Employee E3 confirmed that the opened multi-dose vial of Tuberculin should contain a label indicating the date it was opened. During an interview on 9/14/23, at 8:45 a.m. the Director of Nursing confirmed that the unlabeled, undated Lispro, undated Tuberculin multi-dose vial, and the expired Lantus should have been discarded. 28. Pa. Code 201.18(b)(1) Management 28. Pa. Code 211.9(a)(1) Pharmacy services 395248 Page 9 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0761 28 Pa. Code 211.12(d)(1) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395248 Page 10 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on review of facility grievances and resident council minutes, observations and resident and staff interviews, it was determined that the facility failed to provide sufficient staff to carry out the functions of the food and nutrition services in the main kitchen and delay of meal service to residents. Findings include: Review of the tray line delivery times dated 1/18/22, revealed A Wing residents (the last unit delivered) were scheduled to receive their lunch at 12:00 p.m. Review of the June Resident Council Minutes indicated concerns voiced regarding meal times. Review of the July and August grievance logs revealed 14 complaints regarding dietary concerns and that staff were educated. Eleven resident interviews (Residents R14, R27, R44, R48, R56, R57, R58, R64, R75, and R83) all indicated that all meals are not delivered timely. The interviews indicated that residents have been receiving breakfast as late as 10:00 a.m., lunch as late as 2:00 p.m. and dinner as late as 8:00 p.m They all indicated that this has been an ongoing issue since June. Observations on 9/12/23 and 9/13/23, at 1:00 p.m. or one hour late, revealed that the meal trays destined for A Wing left the kitchen. During an interview on 9/11/23, at 11:00 a.m [NAME] Employee E9 confirmed that there were only two staff for the morning shift and that there was only one cook due to call offs. During an interview on 9/14/23, at 11:15 a.m. the Nursing Home Administrator confirmed that the cook called off the morning of 9/13/23, delaying the meal delivery times. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(3) Management 395248 Page 11 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policies, observations, and staff interview, it was determined the facility failed to properly store foods/maintain proper sanitation in the main kitchen. Residents Affected - Many Findings include: Review of facility policy entitled, Cleaning Dishes/Dish Machine last reviewed 8/03/23, revealed that Low Temperature Dishwasher using chemicals to sanitize that the wash temperature should be 120 degrees Farenheit and that the final rinse sanitization should be at 50 parts per million (50 PPM). It further indicated that staff should check to ensure that the soap and sanitizer are dispensing properly and thermal strips should be used. Review of facility policy entitled, Cleaning Instructions: Freezers last reviewed 8/03/23, revealed that freezers will be defrosted as needed (when the frost is greater than or equal to 1/4 inch thick, the freezer should be defrosted). Review of the EcoLab Operation Manual dated 10/29/07, for the ES Series Chemical Sanitizing Dishmachine, indicated for daily machine preparation to check levels in all chemical containers and replace if empty. Observations on 9/11/23, at approximately 2:00 p.m. and again on 9/12/23, at 10:00 a.m. revealed the dishmachine was being used without any chemical sanitization. Observations on 9/12/23, at 8:55 a.m. of the freezers in the basement area, there was an excessive accumulation of ice on the top shelf and door of Freezer 1, that filled the shelf and only a corner of a product on that shelf was slightly observable. Freezer 3 had an accumulation of ice on the top shelf and a deep freezer also had an accumulation of ice inside. During the above observations and review of information, the Dietary Manager confirmed that the dishmachine was operating without the chemical sanitizer and the freezers should not have excessive accumulation of ice. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.6(f) Dietary services 395248 Page 12 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility documents, and clinical records, observations, and staff interview, it was determined that the facility failed to ensure proper documentation regarding treatment and services for one resident receiving wound care (Resident R1), and administration of medications for 16 residents on the C Hall Unit (secured unit). Findings include: Review of Resident R1's clinical record revealed an admission date of 3/22/07, with diagnoses that included Cerebral Palsy, high blood pressure, diabetes, schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood) and anxiety and was a female. Review of Resident R1's clinical record revealed skin/wound notes by a Certified Registered Nurse Practioner (CRNP) on the following dates: 9/12/23, 9/09/23, 8/29/23, 8/22/23, 8/15/23, 8/08/23, 8/01/23, 7/25/23 and 7/18/23, all indicating that the patient is a [AGE] year old male. During an interview on 9/13/23, at 2:15 p.m. the Nursing Home Administrator confirmed that the skin/wound notes were documented in error regarding Resident R1 being a female. Review of a facility policy entitled Administration Procedures for All Medications dated 8/03/23, indicated that after administration staff are to document the administration in the Medication Administration Record (MAR). Review of September 2023 MARs for residents on the C Hall Unit revealed a lack of documentation that physician prescribed evening medications were administered on 9/09/23. Review of a facility document entitled Medication Administration Audit report provided on 9/13/23, indicated that the 16 residents on C Hall Unit did not receive physician prescribed medications on the evening shift of 9/09/23. During an interview on 9/13/23, at 9:00 a.m. the Director of Nursing confirmed that there was no documentation to support that physician prescribed medications were administered to 16 residents on C Hall Unit on 9/09/23. 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.5(f)(x) Medical records 395248 Page 13 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on review of Hospice contract, clinical records, and staff interviews, it was determined that the facility failed to make certain that Hospice documentation was maintained in the clinical record for two of 22 residents reviewed (Residents R1 and R80). Findings include: Review of facility Hospice contract dated 1/26/10, indicated that Hospice and Facility shall communicate with each other on a regular basis and each party is responsible for documenting such communications in it's respective clinical records to ensure that the needs of Hospice Patients are met; facility shall prepare and maintain complete and detailed records concerning each Hospice patient and each clinical record shall completely, promptly, and accurately document all services provided to, and the events concerning, each Hospice resident, including progress notes; and each record shall document that the specified services are furnished. Review of Resident R1's clinical record revealed an admission date of 3/22/07, with diagnoses that included Cerebral Palsy, high blood pressure, diabetes, schizoaffective disorder and anxiety, and a physician's order dated 1/11/22, to admit Resident R1 to Hospice services. Further review of Resident R1's clinical record revealed a lack of evidence of collaboration/communication of Hospice staff schedule and documentation of Hospice communication detailing Hospice services and service dates. Review of Resident R80's clinical record revealed an admission date of 8/20/21, with diagnoses that included sudden respiratory distress, pneumonitis (general term for lung inflammation) due to inhalation of food/vomit, and senile degeneration of the brain, and a physician's order dated 7/15/23, to admit Resident R80 to Hospice services. Further review of Resident R80's clinical record revealed a lack of evidence of collaboration/communication of Hospice staff schedule and documentation of Hospice communication detailing Hospice services and service dates. During an interview on 9/13/23, at 2:10 p.m. Nurse Assistant (NA) Employee E5, NA Employee E6, Licensed Practical Nurse (LPN) Employee E7, and LPN Employee E8 confirmed that there is no set schedule for Hospice staff, and they do not know when Hospice is coming in, and LPN Employees E7 and E8 confirmed that they receive verbal updates only. During an interview on 9/14/23, at 9:05 a.m. the Director of Nursing confirmed that there was no evidence of a schedule made available to facility staff and no communication sheets provided to facility from Hospice provider. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395248 Page 14 of 15 395248 09/14/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

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, observations, and staff interviews, it was determined that the facility failed to ensure COVID-19 infection control protocols were followed to help prevent the development and transmission of communicable diseases and infections on one of four nursing units (Unit A). Residents Affected - Few Findings include: Review of facility policy entitled COVID-19 Response to an outbreak and residents with exposure, dated 8/3/23, stated place the resident with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the resident should have a dedicated bathroom. If cohorting, only residents with the same respiratory pathogen should be housed in the same room. In general, the residents who are diagnosed with SARS-CoV-2 infection should be maintained in Transmission-Based Precautions. Observations conducted on 9/11/23, at 12:00 p.m. on Unit A revealed a COVID positive resident roomed with a COVID negative resident and sharing a bathroom with two additional COVID negative residents. Further observation revealed the door remained opened, the privacy curtain was not pulled/there was no type of barrier between residents, and there was not a bedside toilet provided. During an interview on 9/11/23, at 12:30 p.m. the Infection Preventionist revealed the resident was isolated in place due to facility having no available rooms and confirmed the facility did not implement additional interventions to protect the roommate as well as the other two residents who share a bathroom with the COVID positive resident During an interview on 9/11/23, at 12:15 p.m. the Director of Nursing confirmed that the facility failed to implement additional interventions to protect the roommate and the other two residents who shared the bathroom. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(5) Nursing services 395248 Page 15 of 15