Health inspection·July 25, 2025

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on review of clinical records and facility policy, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days one of five residents reviewed (Resident R5).A facility policy entitled Behavior Health Program dated 4/21/25, indicated that the physician will limit the timeframe for PRN psychotropic mediations to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or prescribing practitioner. Residents R5's clinical record revealed an admission date of 1/13/24, with diagnoses that included bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs, called mania, and lows, known as depression) liver failure, difficulty eating, gall stones, and heart disease. The clinical record revealed a new physician's order dated 6/22/25, to administer Lorazepam (antianxiety medication) every six hours as needed for 45 days. Further review of Resident R5's clinical record lacked evidence of a physician's rationale for ordering the psychotropic medication past the 14-day limit. Resident R5's clinical record contained a plan of care for ordered anti-anxiety medications and included Ativan (Lorazepam) PRN for 14 days and that it was reordered on 6/22/25, for 45 days. During an interview on 7/24/25, at 2:40 p.m. the Nursing Home Administrator confirmed that there was no evidence of a physician's rationale for ordering the PRN Lorazepam for 45 days. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Page 1 of 4 395248 395248 07/25/2025 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 Residents Affected - Some 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 interviews, it was determined that the facility failed to serve food in a safe and sanitary manner during tray line and ensure that food was stored in accordance with standards for food safety, and failed to label food brought into the facility with the resident's name and use by date, and failed to maintain sanitary conditions in one of two pantry refrigerators (CD Unit). Findings include: A facility policy entitled Bare Hand Contact with Food and Use of Plastic Gloves dated 4/21/2025, indicated Single-use gloves will be worn when handling food directly with hands to assure that bacteria is not transferred from the food handlers' hands to the food product being served. The policy further stated that anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. Examples include after handling boxes, crates, or packages; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and any time a contaminated surface is touched. A facility policy entitled Food Availability dated 4/21/2025, indicated cleaning and sanitizing refrigerators on a regular cleaning schedule, and as needed. A facility policy entitled Food Brought in from Outside Sources and Personal Food Storage dated 4/21/2025, indicated food and beverages brought in from outside sources that require refrigeration or freezing should be labeled with the resident's name and date and stored in the refrigerator / freezer apart from facility food. A facility policy entitled Food Safety for Your Loved One dated 4/21/2025, indicated food in unmarked or unlabeled containers should be marked with the current date the food item was stored and the resident's name. Observation on 7/22/25, at 11:43 a.m. during tray line, revealed that Dietary Employee E2 left the kitchen area with gloved hands, went into the store room closet in hallway, grabbed a large can of chicken noodle soup, came back into the kitchen and opened the can of soup utilizing a can opener, poured the soup into a pan on the stove top, went to the sink, turned on the water and filled the soup can, poured the water into the pan of soup on the stove top, and then threw away the can. Immediately after this at 11:46 a.m. Dietary Employee E2 was observed grabbing a hamburger bun with his/her gloved hand, placing the bun on a plate, using utensils he/she put a hamburger on the bun, grabbed a slice of cheese with his/her gloved hand and placed it on the burger. Immediately after this at 11:47 a.m. Dietary Employee E2 grabbed another hamburger bun with his/her gloved hand, placed the bun on a plate, using utensils he/she put a hamburger in a bowl, used his/her gloved hands to break up the burger, put the burger on the bun, grabbed a slice of cheese with his/her gloved hand and placed it on the burger. Dietary Employee E2 then proceeded to grab three premade grilled cheese sandwiches from a tray with his/her gloved hands and placed them in a skillet. At 11:49 a.m. surveyor stopped Dietary Employee E2 and reviewed the above observations with him/her. Dietary Employee E2 confirmed he/she did the aforementioned and stated he/she tries to remember to change his/her gloves and wash his/her hands but did not do it this time. During an interview on 7/22/25, at 11:50 a.m. Dietary Manager was informed of the above observations and confirmed that Dietary Employee E2 should have changed his/her gloves and washed his/her hands after handling the soup can. Observation on 7/22/25, at 2:27 p.m. on CD unit pantry freezer revealed a 20-ounce bottle of Diet Pepsi with no name and no date. Observation on 7/22/25, at 2:28 p.m. on CD unit pantry refrigerator revealed a 12-ounce can of C4 performance energy drink and a plastic bowl with lid containing applesauce with no name and no date. A dried thick yellow substance was observed on the bottom and 2nd shelf of the refrigerator. During an interview on 7/22/25, at 2:33 p.m. Licensed Practical Nurse Employee E1 confirmed resident freezer / refrigerator in CD unit pantry was dirty and contained items that were not labeled as required. 28 Pa. Code 201.14(a) 395248 Page 2 of 4 395248 07/25/2025 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0812 Responsibility of licensee28 Pa. Code 201.18(e)(2.1) Management Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395248 Page 3 of 4 395248 07/25/2025 Transitions Healthcare Autumn Grove Care Center 555 South Main Street Harrisville, PA 16038

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain an effective pest control program to ensure a pest free environment in one of two pantries (CD Unit). Findings include: A facility policy entitled Pest Control dated 4/21/2025, indicated Routine pest control procedures will be in place. Observation of the pantry on CD Unit on 7/22/25, at 2:27 p.m. revealed numerous small flying insects on the walls, around the sink, around the garbage can and around the base of the floor where a portion of the baseboard was coming off. During an interview on 7/22/25, at 2:33 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the presence of small flying insects in the CD pantry. LPN Employee E1 stated they are always bad in here and if someone leaves any food on the counters, it is much worse. The facility was unable to provide any evidence of prior pest control treatment to CD pantry. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3)(e)(2.1) Management Residents Affected - Some 395248 Page 4 of 4