Health inspection·January 15, 2026

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to notify the medical provider of a change in condition for one of four residents (Resident R1).Findings include: Review of the facility policy, Change in Condition dated 4/1/25, indicated it is the policy of the facility to inform residents, medical providers, and the resident representative of a change in the resident's condition. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated 10/30/25, included diagnoses of chronic kidney disease (gradual loss of kidney function) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section C: Cognitive Patterns indicated that Resident R1 did not have cognitive impairment. Review of Resident R1's progress notes since admission on [DATE], through 11/16/25, failed to reveal documentation of tremors, convulsions, seizures, or Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) or Parkinsonism (group of neurological disorders characterized by tremors, stiffness, slowness of movement, and difficulty maintaining balance), or yelling out. Review of the plan of care initiated 7/5/22, indicated that Resident R1 was at risk for complications related to high blood pressure. The goal listed in the care plan was, Resident's blood pressure will range within parameters set by MD. Included in the interventions was, Observe for signs and symptoms of elevated blood pressure (systolic BP >140, diastolic BP >90, dizziness, flush face, headache, nosebleed, nausea/vomiting). Review of a progress note dated 11/17/25, at 1:18 p.m. indicated, it was passed on from 11-7 nurse that resident was having parkinson's like tremors and has no history of. This nurse and cna (nurse aide) adjusted resident numerous times in bed d/t flopping about and rapidly flapping legs with knees bent. resident opens eyes for very short moments. given prn (as needed) pain medication at 11am d/t (due to) yelling out in pain, but not verbal as to where her pain is located. while up in wc (wheelchair), she is arching her back as if she is having a seizure, and snoring very loudly. Resident took 3 bites of sandwich and then immediately started snoring again. RN sup aware and assessed. Review of a skilled nursing note dated 11/17/25, at 2:02 p.m. indicated Resident R1 was yelling out in pain. Sections that indicated medical provider notification resident responsible party notification were documented as na (not applicable). Review of a progress note dated 11/17/25, at 5:07 p.m. indicated that Resident R1 was transported to the hospital for severe back pain. Found with eyes closed, head back hands and arms in posturing position. Legs with spasms and jerking movement. Unable to feed self with rigid hands. Review of a progress note dated 11/17/25, at 7:26 p.m. indicated, Spoke with [hospital nurse] for status update, resident was admitted to ICU (intensive care unit) and intubated (lifesaving medical procedure that uses a tube to keep the airway open to breathe). Per [hospital nurse] ‘she tanked when she arrived at ER, resident became unresponsive and BP (blood pressure) and temp dropped significantly, Page 1 of 3 395585 395585 01/15/2026 Transitions Healthcare North Huntingdon 8850 Barnes Lake Road North Huntingdon, PA 15642

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she is septic and had to intubated.' Review of Resident R1's vital sign record indicated that her oxygen level on 11/17/25, was documented at 92% at on room air at 1:15 p.m. and 91% on room air at 3:04 p.m. Further review of the oxygen level records failed to reveal a percentage lower than 95% since her admission date. Review of Resident R1's vital sign record indicated that her temperature of 97.1?ahrenheit was flagged by the electronic charting system as abnormal on 11/17/25, at 1:15 p.m. Further review of the clinical record failed to reveal documentation that the medical provider was notified of a change in condition when it occurred. During an interview on 1/13/26, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to notify the medical provider of a change in condition for one of four residents. 28 Pa. Code 201.18 (b)(1) Management. 28 Pa. Code 201.29(d) Resident rights. 28 Pa. Code 211.10 (c)(d) Resident care policies. 28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services. 395585 Page 2 of 3 395585 01/15/2026 Transitions Healthcare North Huntingdon 8850 Barnes Lake Road North Huntingdon, PA 15642

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed (Residents R2 and R3). Findings include: Review of facility policy Administration Procedure for All Medications dated 04/01/25, indicated that medications will be administered in a safe and effective manner. The policy further stated, Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to administration. Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE]. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/25/25, included diagnoses of COPD and high blood pressure. Review of a physician order dated 3/20/25, indicated to give 12.5 mg (milligrams) of metoprolol (a medication to treat elevated blood pressure) one time per day. The order further stated to hold the medication if the systolic blood pressure was less than 100 (mm Hg). Review of Resident R2's January 2026 Medication Administration Record (MAR) revealed the scheduled medication was administered on the following dates:-1/08/26, blood pressure documented in the MAR as 98/61.-1/09/26, blood pressure documented in the MAR as 98/61.-1/10/26, blood pressure documented in the MAR as 98/63.-1/12/26, blood pressure documented in the MAR as 87/56.-1/13/26, blood pressure documented in the MAR as 97/54. Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE]. Review of Resident R3's MDS dated [DATE], included diagnoses of diabetes and high blood pressure. Review of a physician order dated 12/27/25, indicated to give 5 mg of lisinopril (a medication to treat elevated blood pressure) one time per day. The order further stated to hold the medication if the systolic blood pressure was less than 120 (mm Hg). Review of Resident R3's failed to include documentation of a blood pressure measurement since 12/29/25. During an interview on 1/15/25, at 1:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that residents are free of significant medication errors for two of five residents reviewed. 28 Pa. Code: 201.14(a) Responsibility of licensee.28 Pa. Code: 201.18 (b)(1) Management.28 Pa. Code: 211.10 (c)(d) Resident Care policies.28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services. Residents Affected - Some 395585 Page 3 of 3