Health inspection·November 15, 2023

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility documentation and staff interviews, it was determined that the facility failed to ensure facility staff were properly trained to provide basic life support including, Heimlich Maneuver (emergency life-saving procedure that is done immediately when a person is choking which can increase the chances of survival after choking) and cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) for 85 of 135 facility personnel. Findings include: Review of facility policy entitled Cardiopulmonary Resuscitation dated [DATE], revealed facility personnel will be trained on the imitation of cardiopulmonary resuscitation and basic life support. Review of facility policy entitled Foreign Body Airway Obstruction Management dated [DATE], revealed facility personnel will be trained on the procedure for foreign body airway obstruction. Review of the facility personnel CPR certification records as of [DATE], revealed 85 out of 135 staff personnel lacked evidence of completing basic life support including the Heimlich Maneuver and or CPR with the component of hands-on practice and in-person skills assessment. Further review of facility personnel CPR certification records revealed 34 CPR certifications were through National CPR Foundation. Review of National CPR Foundation training program revealed that the program does not include completion of hands-on practice and in-person skills assessments. The National CPR Foundation program indicated Learn useful-life skill techniques through video demonstration. Review of facility personnel CPR certification records revealed one certification through the National Health and Safety Association. Review of the National Health and Safety Association program revealed that the program does not include completion of hands-on practice and in-person skills assessment. The National Health and Safety Association program indicated No manikin required. Review of facility personnel CPR certification records revealed one certification through the American Health Care Academy. Review of the certification revealed an internet based activity and does not indicate completion of hands-on practice and in-person skills assessment. Review of facility personnel CPR certification records revealed one certification through CPR Select. Review of CPR Select program revealed that the program does not include completion of hands-on practice and in-person skills assessment. CPR Select program indicated No Skills test required. Page 1 of 14 395248 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0678 Level of Harm - Minimal harm or potential for actual harm Interview with Nursing Assistant (NA) Employee E9 on [DATE], at 10:30 a.m. revealed that on [DATE], he/she was told by facility management to go online and get CPR certified. Interview also revealed that the CPR online training that he/she completed consisted of watching videos and reading material then answering 10 questions. There was no hands-on practice or in-person skills completed. Review of NA Employee E9's CPR certificate revealed it was from the National CPR Foundation. Residents Affected - Some Interview with NA Employee E10 on [DATE], at 10:50 a.m. revealed that on [DATE], he/she was told by facility management to go online and complete CPR training. Interview also revealed that he/she did not complete the training course online. During an interview on [DATE], at 11:15 a.m. the Nursing Home Administrator confirmed there was no evidence that 85 facility personnel completed hands-on practice and in-person skills assessment with the CPR certifications. 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services 395248 Page 2 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of job descriptions, facility cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) records, facility assessment, and staff interviews, it was determined that the facility failed to ensure that licensed nursing staff have the specific competencies and skill sets necessary to care for resident's needs. Findings include: Review of facility Job Description entitled Licensed Practical Nurse dated 3/2017, revealed that CPR and AED (Automated External Defibrillator-medical device used to help those experiencing sudden cardiac arrest) certification are minimum requirements to perform the job. The review also revealed an essential job function is to attend in-services and/or educational programs in accordance with company and regulatory requirements. Review of Job Description entitled Certified Nursing Assistant dated 3/2017, revealed an essential job function is to attend in-services and/or educational programs in accordance with company and regulatory requirements. Review of Job Description entitled Registered Nurse dated 3/2017, revealed that CPR and AED certification are minimum requirements to perform the job. The review also revealed the Registered Nurse ensures that standards of nursing care are upheld, and policies and procedures are followed. Review of the Facility assessment dated 10/2023, revealed the column Frequency relative to benchmark on the assessment identified that a category for swallowing difficulty and residents with mechanically altered diets was very high which indicated an increase need of competent staff for basic life support including, Heimlich Maneuver (emergency life-saving procedure that is done immediately when a person is choking which can increase the chances of survival after choking) and CPR. Review of facility personnel CPR records revealed 85 out of 135 staff lacked evidence of completing basic life support including the Heimlich Maneuver and/or CPR with the component of hands-on practice and in-person skills assessment. Therefore, the facility's CPR records lacked evidence that 85 of 135 facility staff were evaluated and assessed to be competent in basic life support including the Heimlich Maneuver and CPR. Interview with Nursing Assistant (NA) Employee E10 on [DATE], at 10:30 a.m. revealed that he/she completed CPR online training that consisted of watching videos and reading material then answering 10 questions. There was no hands-on practice or in-person skills completed. The interview also revealed he/she was not trained in basic life support including the Heimlich Maneuver. Interview with NA Employee E11 on [DATE], at 10:50 a.m. revealed that he/she was not trained in Basic Life Support including the Heimlich Maneuver and/or CPR certified. Interview with NA Employee E12 on [DATE], at 10:35 a.m. revealed that he/she was not trained in Basic Life Support including the Heimlich Maneuver and or CPR certified. 395248 Page 3 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with Licensed Practical Nurse (LPN) Employee E4 on [DATE], at 12:45 p.m. revealed that he/she was not provided with training on emergency response including basic life support, Heimlich Maneuver and CPR, and what to do once an emergency is identified to prevent a condition from worsening. Interview with LPN Employee E5 on [DATE], at 12:47 p.m. revealed that he/she was not provided with training on emergency response including basic life support, Heimlich Maneuver and CPR, and what to do once an emergency is identified to prevent a condition from worsening. During an interview on [DATE], at 11:00 a.m. the Director of Nursing (DON) confirmed they have not conducted any type of competencies or mock drills regarding STAT (a term used in the medical field for response to an emergency) situations with staff since he/she has been employed there, which has been over one year. The DON also confirmed that competencies should be completed for staff. During an interview on [DATE], at 11:15 a.m. the Nursing Home Administrator confirmed there was no evidence that 85 facility personnel completed hands-on practice and in-person skills assessment with the CPR certifications. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395248 Page 4 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on review of clinical records, facility documents and coroner's report, and staff interviews it was determined the facility failed to provide food in a form designed to meet individual needs for one resident (Resident R1) who choked and ceased to breath as a result. This failure placed nine residents that had similar diet needs for bite-sized pieces at a high risk for death and resulted in an Immediate Jeopardy situation for Residents R2, R3, R4, R5, R6, R7, R8, R9, and R10. Findings include: Review of Resident R1's clinical record revealed an admission date of 8/08/23, with diagnoses that included alcoholic myopathy, muscle weakness, unsteadiness on feet, and dysphagia (difficulty swallowing). Review of physician's orders revealed that Resident R1's diet was regular texture with meats cut into bite-size pieces, allowed thin liquids with direct supervision and meal trays, and nectar thick liquids at bedside. Review of Resident R1's clinical record revealed he/she was followed by Speech Therapy from 9/12/23-10/11/23 Therapy notes indicated due to documented physical impairments and associated functional deficits, without skilled therapeutic interventions that Resident R1 was at risk for aspiration (food or liquid entering the airway) and that Resident R1 required supervision/assistance at mealtime due to swallowing safety 50 percent to 75 percent of the time. Review of Resident R1's care plan revealed that he/she was to be monitored and staff to document and report to the physician for signs and symptoms of dysphagia, pocketing, choking, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat. The care plan also indicated that Resident R1 appears concerned during meals. Review of Resident R1's meal ticket revealed he/she was to have thin liquids in a regular cup with a Rije cup (a drinking aid for people with swallowing disorders) on the side and a spouted cup for nectar thick liquids (slightly more body than thin liquids used for people with swallowing disorders). An alert on the meal ticket revealed that Resident R1 was to have cut meats. Review of facility bite sized diet guidelines revealed, Soft & Bite-Sized This diet restriction is intended for those that have some chewing ability to break food into smaller pieces and move food around in order to swallow safely. Food served on this diet must be soft and tender, with particle sizes no larger than 1.5 centimeters x 1.5 centimeters (0.59 inches). Review of facility hotdog order revealed that two cases of Smithfield Beef Franks, five count per pound, frozen, 10-pound package was delivered on 10/10/23. The Smithfield Beef [NAME] served on 10/11/23, were 91 grams per hotdog, when compared to a Ball Park Beef Hot Dog, original length which are 53 grams per hotdog. This information identified that the hotdogs served at the facility on 10/11/23 were almost double the size of a regular hotdog. During an interview on 10/31/23, at 1:55 p.m. Dietary Staff Employee E9 stated, the hotdog was cut, but not in bite-size pieces, the hotdog was in a bun and cut into four equal pieces and there was only one piece of the hotdog left on [Resident R1's] tray and that [Resident R1] did not eat any of 395248 Page 5 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some the bun. He/she confirmed that the hotdogs were larger than a normal hotdog that you would buy at the grocery store. Subsequent interview with Dietary Staff Employee E9 on 11/1/23, at approximately 1:30 p.m. revealed that he/she provided a description of a bite-sized diet from the facility's diet manual and that a bite-size diet food should be cut into 0.59-inch sized pieces. He/she also said they do not follow this diet that is in the manual because it is not in their electronic system, but it is a good reference to use when a resident is ordered a bite-size diet. Review of physician's orders for Residents R2, R3, R4, R5, R6, R7, R8, R9, R10, revealed all had diet orders comparable to Resident R1 with orders in place for bite-sized meat. Review of the facility policy entitled, Therapeutic Diets Provided To Residents in Long-Term Care last reviewed 8/3/23, revealed, To assure provision of the appropriate diet for each resident and to maximize resident care . Review of information submitted by the facility dated 10/11/23, revealed, .Coroner notified writer that cause of death was accidental, asphyxiation (lack of oxygen and impaired respiration, suffocation), removal of piece of hot dog from resident's airway. Resident's diet was as follows: Regular textures with meats cut into bite-size pieces, sugar substitute, allowed thin liquids with direct supervision and meal trays, nectar thick liquids at bedside. Review of facility investigation documentation revealed the following written staff interviews: Review of Occupational Therapist Employee E6's written statement on 10/11/23, at 11:40 a.m., revealed, called C/D lounge by RN [Registered Nurse Employee E1] walking down to C/D lounge- entered C/D lounge resident sitting in dining room armed chair with drool noted on lips, lips lightly blue, and cool to touch, arms resting relaxed at sides, eyes barely open. No active movement observed occasional gasp (whole body) therapist supported resident in upright position-CNA [Certified Nurse Aide Employee E7] was behind resident having stated completed Heimlich and upon walking to dining room audibly heard back thrusts being performed, RN [Employee E1], LPN [Licensed Practical Nurse] Employee E5, CNA [Employee E7], LPN [Employee E4] transferred resident out of armed chair into broda [type of positioning chair] wheelchair. Assist from CNA staff Tray without Rije cup. Hot dog pieces all gone but one and bun intact. OT only drink consumed. The facility investigation lacked a written statement for CNA Employee E7 who was the staff member that was in the D-Wing Lounge at the time Resident R1 started to choke. Interview with LPN Employee E4 on 10/31/23 at 12:35 p.m., revealed that he/she had no training on emergency response such as a STAT call over the intercom. He/she was in the facility at time of incident and heard another LPN Employee E5 yelling. He/she went to the lounge and saw Resident R1 going unresponsive, he/she was unsure if the resident was choking at that time and then looked down at Resident R1's meal and noticed a hotdog in front of Resident R1 and that it was not a normal hot dog it was a jumbo hotdog. He/She then smacked Resident R1 on the back and did a finger sweep which he/she did not find anything. He/she stated that Resident R1 is known for eating too fast and attempting to eat too much food at once, so Resident R1 had to be monitored for safety. He/She identified that Nursing Assistant Employee E7 was the only staff member in the D-Wing Lounge at that time and did not see anyone performing the Heimlich on Resident R1. He/She stated that there was no crash cart/suctioning brought to the lounge and that Resident R1 was a DNR with a limited POLST. 395248 Page 6 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0805 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of the Resident R1's autopsy report completed by the coroner dated 10/11/23, revealed there was 3.5 x 2.5 x 2 centimeters [cm--2.54 centimeters equal to one inch] piece of hotdog lodged and blocking the larynx/trachea and numerous large pieces of hotdog in the stomach. Review of Resident R1's death certificate identified the main cause of death as asphyxiation (being deprived of oxygen which can result in suffocation or death) related to choking on a bolus (ball like mixture of food and saliva) of food. The facility failed to provide food in a form designed to meet individual needs for one resident (Resident R1) who choked and ceased to breath as a result. This failure placed eight residents that had similar diet needs related to bite-sized pieces at a high risk for death and resulted in an Immediate Jeopardy (IJ) situation for Residents R2, R3, R4, R5, R6, R7, R8, and R9. The Nursing Home Administrator (NHA) was notified of the IJ situation on October 31, 2023, at 4:39 p.m. and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA and the Director of Nursing on October 31, 2023, and approved at 6:31 p.m. The approved plan included: 1. Facility already implemented plan through our QAPI committee on October 19, 2023. 2. Facility has reviewed all resident diets to ensure proper diets are provided, completed on October 12, 2023. This review was completed by Dietician, Speech Therapist, Director of Rehabilitation, Certified Dietary Manager, Nursing Home Administrator, and Director of Nursing. 3. Diets have been altered for safety reasons based on residents' needs, orders have been updated as of October 16, 2023. 4. Staff have been educated ensuring food is served in accordance with ordered diet. This education occurred on October 25, 2023. 5. Hot Dogs, and other tubular meats, were removed from the facility menus on October 12, 2023. 6. Audits are being completed five days per week for four weeks, then three days per week for four weeks, then weekly for four weeks. All audits will be taken to QAPI. 395248 Page 7 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0805 On November 1, 2023, between 10:45 a.m. and 3:15 p.m. observations, staff interviews, and review of facility policy, and education, verified that the facility had implemented the above identified action plan. Level of Harm - Immediate jeopardy to resident health or safety The Immediate Jeopardy was removed on November 1, 2023, 2:45 p.m. when the action plan implementation was verified. Residents Affected - Some 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395248 Page 8 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Minimal harm or potential for actual harm Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that professional licensed staff implemented life-saving interventions in response to a choking episode that led to death and failed to ensure the provision of food in a form to meet individual resident needs. Residents Affected - Some Findings include: Review of the job description for the NHA revealed that the NHA's purpose is to lead and direct the overall operations of the nursing home facility in accordance with customer needs, government regulations, and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business operations. The NHA's essential job functions include being responsible to ensure quality and proper resident care and services and possess and display a practical knowledge of nursing facility operations. Review of the job description for the DON revealed that the DON's purpose is to manage the overall operations of the Nursing Department in accordance with company policies, standard nursing practices, and regulatory guidelines. The DON's essential job functions include being responsible to monitor and analyze clinical reports including falls, weights, wounds, dietary consultants, pharmacy consultants, etc. and take appropriate actions, assume administrative authority, responsibility and accountability for all functions, activities, and training of the Nursing department, and ensure nursing staff is educated and prepared to perform duties at an acceptable level. Based on the findings that the facility failed to ensure that professional licensed staff implemented life-saving interventions in response to a choking episode that led to death and failed to ensure the provision of food in a form to meet individual resident needs for all residents, the NHA and the DON failed to fulfill their purpose and essential job duties to ensure that the Federal and State guidelines and regulations were followed. Refer to F836 and F805 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 201.18(a) Management 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing Services 28 Pa. Code 211.12(d)(1)(5) Nursing Services 395248 Page 9 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0836 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Many Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. Based on review of facility policy, clinical records, facility documents, staff documentation, and coroner's report and staff interviews, it was determined the facility failed to provide emergency life-saving interventions as required for one resident who was choking and still breathing where professional licensed staff did not attempt life-saving interventions to Resident R1 as required. This failure placed all 100 residents that may have needed emergency life-saving interventions, at a high risk for death and resulted in an Immediate Jeopardy situation. Findings include: Review of the facility policy entitled, Foreign Body Airway Obstruction Management, last reviewed 8/3/23, revealed, Facility personnel will be trained on the procedure for Foreign-Body Airway Obstruction [Heimlich Maneuver]. The Heimlich Maneuver is used on conscious adults and thrusts are to continue even if the resident loses consciousness in an attempt to dislodge an obstruction. Review of facility documents entitled, Job Description-Registered Nurse Supervisor revealed that Registered Nurse (RN) Supervisors are expected to assist with or institute emergency measures for sudden adverse developments in residents. Review of Resident R1's clinical record revealed an admission date of 8/08/23, with diagnoses that included alcoholic myopathy (disease of muscle tissue), muscle weakness, unsteadiness on feet, and dysphagia (difficulty swallowing). Review of physician's orders revealed that Resident R1's diet was regular textures with meats cut into bite size pieces, allowed thin liquids with direct supervision and meal trays, nectar thick liquids at bedside. Resident R1 was followed by Speech Therapy from 9/12/23-10/11/23. Therapy notes indicated that due to documented physical impairments and associated functional deficits, without skilled therapeutic interventions Resident R1 was at risk for: aspiration (food or liquid entering the airway) and that Resident R1 required supervision/assistance at mealtime due to swallowing safety 50 percent to 75 percent of the time. Review of Resident R1's care plan revealed that he/she was to be monitored and staff to document and report to the physician for signs and symptoms of dysphagia, pocketing, choking, drooling, holding food in mouth, several attempts at swallowing, and refusing to eat. The care plan also indicated Resident R1 appears concerned during meals. Review of Resident R1's POLST [Pennsylvania Orders for Life-Sustaining Treatment] dated 8/09/23, revealed FIRST follow these orders, THEN contact physician, Certified Registered Nurse Practitioner [CRNP] or Physician Assistant. This is an Order Sheet based on the person's medical condition and wishes at the time the orders were issued. Everyone shall be treated with dignity and respect. The POLST was signed by both the physician and Resident R1 and Section A revealed that if the person has no pulse and is not breathing DNR [Do Not Attempt Resuscitation] Allow Natural Death. Section B revealed Medical Interventions person has pulse and/or is breathing as Limited Additional Interventions. Section B was signed by both the physician and Resident R1 revealed the resident wanted oral suction 395248 Page 10 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0836 and manual treatment of airway obstruction. Level of Harm - Immediate jeopardy to resident health or safety Review of information submitted by the facility dated 10/11/23, revealed, Registered Nurse Supervisor [Employee E1] response STAT [immediately/without delay] to D wing lounge and noted that Resident R1 was nonresponsive, lips cyanotic, resident taking gasps. Residents Affected - Many Review of progress notes revealed documentation completed by RN Employee E1 on 10/11/23 at 12:12 p.m., which stated, writer called to d lounge. [Resident R1] nonresponsive, lips cyanotic, resident taking gasp. No spo2 [blood oxygen level] obtainable . in house and paged to room. Resident seen one hour prior by CRNP [Certified Registered Nurse Practitioner]. CRNP at her side. No chest movement. No pulse. POLST verified several times. CRNP states CTB [ceased to breath] at 11:40 a.m. Brother .notified. Brother coming to see resident. Review of facility investigation documentation revealed the following written staff interviews: Review of Certified Nursing Assistant [CNA] Employee E2's written statement revealed on 10/11/23, I was feeding another resident. He/She was starting to spit out food after a few bites. I took him/her up by the nurse's station and then I had to talk to the Therapy lady up at the nurse's station. I didn't come back in like usual to feed a couple other residents in there. Review of CNA Employee E3's written statement revealed, on 10/11/23, at 11:30 a.m. I helped pass a few trays in D-Lounge. When I left the D-Lounge [CNA Employee E7] was still passing trays. I left to toilet a resident on another hall who had been asking to go at the time trays arrived. Trying to self-transfer. After toileting resident, I was at the desk when I heard [CNA Employee E7] yell for LPN [Licensed Practical Nurse Employee E4] in D-Lounge. That is when I heard [Resident R1] choking. His/her code status was looked up and RN [Employee E1] was called. I did not go down to the lounge at this time, I moved residents in the hall to make a path for anybody who needed to get there quickly. Review of LPN Employee E4's written statement on 10/11/23, revealed, called to the lounge by other LPN [Employee E5]. This nurse went into lounge LPN [Employee E5] and CNA [Employee E7] were in the lounge. They stated they weren't sure what was going on with [Resident R1]. His/her color was dusky. His/her eyes were big. I asked [Resident R1] if he/she was choking, [Resident R1] looked at me and then went unresponsive. I ran to look at POLST and told LPN [Employee E5] to call RN [Employee E1]. POLST said DNR. I ran and got RN [Employee E1], and we ran back to the lounge. Review of LPN Employee E5's written statement on 10/11/23, revealed, I was walking down D hall to pass 11 a.m. meds. I stopped in the lounge to ask an aide [Employee E7] a question. When I walked in the resident looked like he/she was going to cough, but she didn't make any noise. Then the resident looked like she was choking. [CNA Employee E7] patted her on the back a couple of times. Resident started looking blue. I ran and grabbed my pulse ox. Resident coughed quietly. [CNA Employee E7] did Heimlich. Resident just turned more blue. I yelled for the resident's nurse, [LPN Employee E4] came. I called [RN Supervisor Employee E1] on the phone to come now. [He/she] came pretty quick. We checked resident was a DNR. She was blue but was still taking a quick breath now and then. The nurse practioner came. We got her in a chair and took her to her room. They called her time of death. The lunch tray cart was in the lounge while they were eating. Review of Occupational Therapist Employee E6's written statement on 10/11/23 at 11:40 a.m., revealed, called C/D lounge by RN [Employee E1] walking down to C/D lounge- entered C/D lounge resident sitting in dining room armed chair with drool noted on lips, lips lightly blue, and cool to touch, arms 395248 Page 11 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0836 Level of Harm - Immediate jeopardy to resident health or safety resting relaxed at sides, eyes barely open. No active movement observed occasional gasp (whole body) therapist supported resident in upright position-CNA [Employee E7] was behind resident having stated completed Heimlich and upon walking to dining room audibly heard back thrusts being performed, RN [Employee E1], LPN [Employee E5], CNA [Employee E7], LPN [Employee E4] transferred resident out of armed chair into broda wheelchair. Assist from CNA staff Tray without Rije cups. Hot dog pieces all gone but one and bun intact. OT only drink consumed. Residents Affected - Many Subsequent interview conducted with RN Employee E1 on 10/31/23, at approximately 9:15 a.m., revealed that he/she gave a statement that was sent to the Department of Health; he/she stated it was a bad day and he/she was monitoring in the dining room at the time of the incident. He/She got called to D-wing Lounge and went there after gathering the CRNP, upon arrival the resident took like two gasps of air and then stopped breathing, he/she was a DNR so did not initiate CPR (cardiopulmonary resuscitation). Subsequent interview with LPN Employee E4 on 10/31/23, at 12:35 p.m., revealed, that he/she had no training on emergency response such as a STAT call over the intercom. He/she was in the facility at time of incident and heard another LPN Employee E5 yelling. He/she went to the lounge and saw Resident R1 going unresponsive, he/she was unsure if the resident was choking at that time and then looked down at Resident R1's meal and noticed a hot dog in front of Resident R1 and that it was not a normal hotdog it was a jumbo hotdog. He/She then smacked Resident R1 on the back and did a finger sweep which he/she did not find anything. He/she stated that Resident R1 is known for eating too fast and attempting to eat too much food at once, so Resident R1 had to be monitored for safety. He/She stated that Nursing Assistant Employee E7 was the only staff member in the D-Wing Lounge at that time and did not see anyone performing the Heimlich on Resident R1. He/She stated that there was no crash cart/suctioning brought to the lounge and that Resident R1 was a DNR with a limited POLST. Subsequent interview with LPN Employee E5 on 10/31/23, at 12:56 p.m., revealed that he/she had no training on emergency response such as a CPR or STAT code. LPN Employee E5 stated that when he/she entered the lounge the resident looked funny, and his/her body was flopping; Resident R1 was blue in color. LPN Employee E5 stated they ran to get the pulse ox and called the RN Employee E1 on the portable phone while in the lounge. LPN Employee E5 stated that CNA Employee E7 was performing the Heimlich 3 or 4 times and Resident R1 was slow breathing; Resident R1 was slow breathing when RN Employee E1 entered the room, described the breaths as slow with longer than normal gaps in-between, but confirmed that Resident R1 was still moving air. He/she did not see anyone else perform the Heimlich on Resident R1; the crash cart/suctioning was not brought to the lounge. Interview conducted on 10/31/23, at 11:00 a.m. with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed, they both responded to the D-Wing Lounge after hearing the alert over the intercom. They stated they entered at the same time as the RN Employee E1 and CRNP Employee E8 and it happened in seconds. Advised there was not any time to call 911 and as they entered, Resident R1 took a couple of more breaths and then he/she was gone. They were unable to provide a statement regarding a timeline and advised the crash cart/suctioning was not taken to the lounge. The DON confirmed they have not conducted any type of competencies or mock drills regarding STAT situations with staff since he/she has been employed there, which has been over 1 year. Statement received via e-mail from CRNP Employee E8 on 10/31/23, at 1:42 p.m. revealed, The patient was seen early morning 10/11/23 in stable condition. I was called to the small lounge on the D Hall due to the patient being unresponsive. Upon arrival to the lounge the patient was slumped over in a chair. She had no pulse or respirations. It was communicated to me that she is a DNR. Nursing staff 395248 Page 12 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0836 Level of Harm - Immediate jeopardy to resident health or safety reported they were not aware of the patient eating any food from her lunch tray. She was taken back to her room and the coroner was notified. The facility investigation lacked a written statement for CNA Employee E7 who was the staff member that was in the D-Wing Lounge at the time Resident R1 started to choke and attempted the Heimlich, while yelling for assistance from additional staff. Residents Affected - Many Review of the Resident R1's autopsy report completed by the coroner dated 10/11/23, revealed there was 3.5 x 2.5 x 2 centimeters [cm--2.54 centimeters equal to one inch] piece of hotdog lodged and blocking the larynx/trachea and numerous large pieces of hotdog in the stomach. Review of Resident R1's death certificate identified the main cause of death as asphyxiation (being deprived of oxygen which can result in suffocation and death) related to choking on a bolus (ball like mixture of food and saliva) of food. The facility's Licensed Professional Staff failed to provide emergency life-saving interventions which would have included but are not limited to, continuing the Heimlich Maneuver and/or utilizing suction for one resident who was choking and still breathing. This failure placed all 100 residents that may have needed emergency life-saving interventions, at a high risk for death and resulted in an Immediate Jeopardy (IJ) situation. The NHA was notified of the IJ situation on October 31, 2023, at 4:39 p.m. and was provided the IJ template. An Immediate Action Plan was requested. The Immediate Action Plan was provided by the NHA and the DON on October 31, 2023, and approved at 6:31 p.m. The plan included: 1. Facility already implemented process improvement plan through QAPI committee on October 19, 2023. 2. Facility completed training with staff on responding to emergency choking situations, completed on October 11, 2023. 3. Facility is working with Healthcare Coalition and Superior Ambulance in getting onsite CPR certification class scheduled, began calls to schedule on October 11, 2023. 4. Facility implemented that all licensed staff obtain CPR certification online until and in-person onsite class is confirmed. Certifications are obtained and housed in employees personnel file, implemented on October 11, 2023. 395248 Page 13 of 14 395248 11/15/2023 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0836 5. Level of Harm - Immediate jeopardy to resident health or safety Facility has eliminated the use of Lounge Dining and have all residents dining in the main dining room where suctioning is available and additional staff are present effective October 12, 2023. 6. Residents Affected - Many Audits are being completed five days per week for four weeks, then three days per week f or four weeks, then weekly for four weeks. All audits will be taken to QAPI. On November 1, 2023, between 10:45 a.m. and 3:15 p.m. observations, staff interviews, and review of facility policy, and education, verified that the facility had implemented the above identified action plan. The Immediate Jeopardy was removed on November 1, 2023, 2:45 p.m. when the action plan implementation was verified. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(2)(3) Management 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services 395248 Page 14 of 14