Health inspection·May 30, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm Based on review of clinical record and staff interviews, it was determined that the facility failed to inform a resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for one of three residents (Resident R43). Residents Affected - Few Finding include: Review of the facility's policy, Change of Condition, with a review date of 4/1/25, and 4/1/24, reported that the facility must notify the resident's representative of the change and any changes made to the resident's plan of care and document in the medical record. Assist with any contacts desired between the family, resident, and Physician/CRNP (Certified Registered Nurse Practitioner) within HIPPA guidelines. Attempt to contact the resident representative at frequent intervals, until notified of the change and interventions, and document all attempts to notify resident representative. Review of Resident R43's Minimum Data Set (MDS - periodic assessment of resident care needs), dated 4/22/25, indicated diagnoses of traumatic subarachnoid hemorrhage without loss of consciousness (bleeding between the brain and the tissue covering the brain), dysphagia (difficulty swallowing), diabetes (too high or too low of blood sugar), seizures (abnormal activity in the brain that can cause jerking movements, loss of consciousness, blank stares or other symptoms). Further review of the MDS indicated the resident's Brief Interview for Mental Status assessment (BIMS) was 99 indicating the resident has a severe impairment where they can not complete the interview to obtain a value for mental status. Review of prior physician order dated 4/9/25, indicated Ativan 0.5mg Oral Tablet, Give 1 tablet (0.5mg) once a day for anxiety. Review of the physician orders dated 4/18/25, Ativan 0.5mg Oral Tablet, Give 0.5mg in a.m. Give 0.25 mg at bedtime for anxiety. Review of the physician orders dated 4/18/25, revision 4/28/25, Ativan 0.5mg Oral Tablet, Give 0.25 mg at bedtime for anxiety. Review of the physican orders dated 12/20/24, Haldol 2mg/1ml, Give 0.5 ml Oral Solution twice a day. Review of the physician orders dated 3/13/25, Haldol 2mg/1ml, Give 0.5 ml once a day at bedtime, order was discontinued on 3/20/25. Page 1 of 3 395585 395585 05/30/2025 Transitions Healthcare North Huntingdon 8850 Barnes Lake Road North Huntingdon, PA 15642

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident R43's nurse progress notes April 19, 2025-May 2025 and Psychiatry recommendations from April 2025-May 2025 revealed no evidence that the resident's husband or other representative was notified of the new orders, discussed the advantage and disadvantage of medication decrease and alternative options. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 5/30/25 at 11:22 a.m., confirmed that the facility failed to inform resident's representative in advance of the proposed care, including the risk and benefits of the prescribed medication for Resident R43 as required. 28 Pa Code 201.29(j) Resident Rights. 28 Pa Code 211.10(c) Resident Care policies. 28 Pa Code 211.12(d)(1) Nursing Services. 395585 Page 2 of 3 395585 05/30/2025 Transitions Healthcare North Huntingdon 8850 Barnes Lake Road North Huntingdon, PA 15642

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for one of four residents (Resident R69) A review of the facility policy Administration Procedures For All Medications dated 4/1/25, indicated medications will be administered in a safe and effective manner and after administration document in the MAR (medication administration record) or TAR (treatment administration record) as necessary. A review of the clinical record indicated that Resident R69 was admitted to the facility on [DATE], with diagnoses that included heart disease, dementia, and asthma. A review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/13/25, indicated the diagnoses remained current. A review of Resident R69's physician orders dated 1/23/25, indicated to administer oxygen via n/c (nasal cannula) at 4L (liters) per minute continuously every shift. A review of Resident R69's MAR dated May 2025 did not include documentation that the resident received oxygen as ordered on 5/4, 5/9, 5/13, 5/14, 5/15, 5/20, 5/22, 5/23, and 5/27/25. During an interview on 5/28/25 , at 1:45 p.m. the Nursing Home Administrator confirmed the above findings, and the facility failed to make certain that medical records on each resident are complete and accurately documented for Resident R69. 28 Pa. Code: 211.5(f)(g)(h) Clinical records. 395585 Page 3 of 3