Health inspection·February 6, 2025

F 0584 Pa Code: 207.2 (a) Administrator's responsibility Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395585 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare North Huntingdon 8850 Barnes Lake Road North Huntingdon, PA 15642 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on a review of facility policies, documents, observations and staff interviews it was determined that the facility failed to properly design, approve, and follow the Winter five week cycle menu and modifications of the cycle menu. (Winter menu Cycle weeks one, two, three, four and five). Findings include: A review of the facility's Menu Planning policy date 12/31/24, revealed that menu planning will be completed by the facility at least two weeks in advance of service. Regular and therapeutic diets will be written to provide a variety of foods served, adjusted for seasonal changes and in adequate amounts at each meal to satisfy recommended daily allowances. The registered dietitian (RD) will approve all menus. A review of the facility's Sample Menu Shell for Diet Extensions template date 12/31/24, revealed therapeutic diets include: Regular/Regular no added salt packet, Mechanical soft/moist, minced/ground, Mechanical soft bite size, Pureed, Consistent carbohydrate, and Consistent Carbohydrate Pureed. A review of the facility's Portion Control policy date 12/31/24, revealed that residents will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to make certain that accurate portion sizes are served. The menu should list the specific portion size for each food item. Menus should be posted at the tray line so staff can refer to the proper portions for each diet. A review of the facility's Winter five week cycle menu extension sheets implemented October 2024, revealed that the extension sheets failed to provide guidance for regular and therapeutic diets as outlined on the Sample Menu Shell for Diet Extensions template. The extension sheets failed to provide portion sizes for all diets and the combined guidance for Mechanical soft and Puree diets failed to provide guidance on food item consistency which created the potential for dietary staff to serve inaccurate portion sizes and food consistency. The extension sheets were previously approved (date unknown) by former facility RD Employee E4, her last date of employment with the facility was 12/27/24, the facility failed to provided documented evidence that the facility's RD had reviewed and approved the menu extension sheets as required. During an interview on 2/5/25, at 11:15 am the Food Service Director (FSD) Employee E 2 revealed that the dietary department staff utilizes documents maintained in a binder for guidance regarding portion sizes and food consistencies. A review of these documents revealed the following documents: * SLP (Speech Language Pathologist) Mech (Mechanical) Soft Recommendations which outlined recommendations for residents being served the therapeutic diet Mechanical Soft. The recommendations stated no rice, no raw fruits and vegetables, pineapple is not okay even if ground /pulsed, as well as other recommendations. The document contained no documented evidence of the facility's RD review and approval of these recommendations. * Puree Serving Guidelines which provided guidance for portion sizes indicated that portions range from one half cup to a cup for fruits and vegetables, grains, protein and dairy. It was noted that a typical serving size for a puree diet for seniors is generally to be one half cup to three fourths cup per meal of pureed food. The guidance provided conflicting recommendations of portions sizes for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395585 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395585 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare North Huntingdon 8850 Barnes Lake Road North Huntingdon, PA 15642 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many puree diets which created the potential for inappropriate inaccurate portions of food products served to residents served a puree diet. The document contained no documented evidence of the facility's RD review and approval of the guidance. * Small, Regular and Large Portion Sizes document contained no documented evidence of the facility's RD review and approval of the guidance. A review of the facility's Mechanical Soft/Puree menu extension sheets revealed on Thursday lunch week one of the cycle menu Mechanical soft diets received [NAME] pilaf although the SLP's recommendations failed to permit rice to be served to this diet. On Saturday Dinner week three it was indicated to serve pineapple to Mechanical soft and puree diets although this food product is not permitted for these diets. All five weeks of the Mechanical Soft/Puree menu extension sheets failed to provide food consistency guidance for meals served to resident requiring mechanically altered food products such as chopped, minced, and ground meats as well as pureed food products. During an interview on 2/5/25, at 11:25 am [NAME] Employee E3 confirmed that the Mechanical Soft/Puree menu extension sheet for Saturday Dinner week three permitted pineapple to be served to these therapeutic diets. [NAME] Employee E3 stated she would serve the mechanical soft residents crushed pineapple and a pureed fruit (based on availability) to the residents served a puree diet. She confirmed that the SLP guidance states no pineapple is to be served to residents that receive a Mechanical soft diet. During an interview on 2/5/25, at 11:30 am the FSD Employee E2 confirmed that the facility modified the Wednesday Lunch menu for week three and was serving the residents a chef salad. A review of the facility's substitution log revealed that the facility was substituting chef salad for those resident's that receive a renal diet. A review of the facility's week at a glance menu for cycle week three revealed the modification to the Wednesday lunch menu. The substitution log and the week at a glance menu failed to provide evidence that the facility pre planned the menu modification, menu and substitution review and approval by the facility's RD as required. During an interview on 2/5/25, at 11:30 am the FSD Employee E2 confirmed that the facility failed to properly design, review and approve the facility's Winter five week cycle menu as required which created the potential for conflicting guidance which may result in residents being provide inappropriate and inaccurate portion sizes and food product consistency for their prescribed therapeutic diet. Pa Code: 211.6(a)(b) Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395585 If continuation sheet Page 4 of 4