Health inspection·February 26, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, clinical records, and staff interviews it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eighteen of twenty residents reviewed (Resident R1, R10, R38, R39, R57, R68, R70, R76, R77, R78, R79, R87, R94, R95, R96, R206, R207, R208). Findings include: A review of the facility policy Advanced Directives reviewed 1/13/23 and 1/2/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive. A review of the medical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture), dysphagia (difficulty swallowing) and tracheostomy (a hole made in throat to place a tube into the person ' s trachea or windpipe). A review of the clinical record failed to reveal an advance directive or documentation that Resident R1 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R10 was re-admitted to the facility on [DATE], with diagnoses that include diabetes, high blood pressure, and chronic obstructive pulmonary disease (COPD constriction of the airways making it difficult to breath). A review of the clinical record failed to reveal an advance directive or documentation that Resident R10 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R38 was re-admitted to the facility on [DATE], with diagnoses that include paralysis (no movement of lower body or legs), dysphagia, respiratory failure (disease or injury that causes interference with the lungs to deliver oxygen), and tracheostomy. Review of the clinical record failed to reveal an advance directive or documentation that Resident R38 was given the opportunity to formulate an Advanced Directive. Page 1 of 13 395692 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the clinical record indicated Resident R39 was admitted to the facility on [DATE], with diagnoses that include tracheostomy, muscular dystrophy (genetic condition that causes progressive weakness and loss of muscle mass), diabetes and high blood pressure. A review of the clinical record failed to reveal an advance directive or documentation that Resident R39 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R57 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, chronic pain, and depression. A review of the clinical record failed to reveal an advance directive or documentation that Resident R57 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R68 was re-admitted to the facility on [DATE], with diagnoses of high blood pressure, respiratory failure, and tracheostomy. A review of the clinical record failed to reveal an advance directive or documentation that Resident R68 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R70 was re-admitted to the facility on [DATE], with diagnoses that include diabetes, high blood pressure, and amputation below left knee. A review of the clinical record failed to reveal an advance directive or documentation that Resident R70 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R76 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, COPD, and muscle weakness. A review of the clinical record failed to reveal an advance directive or documentation that Resident R76 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R77 was admitted to the facility on [DATE], with diagnoses that include a stroke (an interruption of the blood flow within your brain that causes the death of brain cells), with paralysis on right side, high blood pressure, and dysphagia. A review of the clinical record failed to reveal an advance directive or documentation that Resident R77 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R78 was admitted to the facility on [DATE], with diagnoses that include stroke, high blood pressure and end-stage renal disease (ESRD - when the kidneys permanently fail to work). A review of the clinical record failed to reveal an advance directive or documentation that Resident R78 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R79 was readmitted to the facility on [DATE], with diagnoses that include amyotrophic lateral sclerosis (ALS - weakens all muscles and impacts physical function), tracheostomy, and depression. 395692 Page 2 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0578 Level of Harm - Minimal harm or potential for actual harm A review of the clinical record failed to reveal an advance directive or documentation that Resident R79 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R87 was admitted to the facility on [DATE], with diagnoses that include high blood pressure, ALS, tracheostomy. Residents Affected - Some A review of the clinical record failed to reveal an advance directive or documentation that Resident R87 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R94 was admitted to the facility on [DATE], with diagnoses that includes respiratory failure, tracheostomy, and high blood pressure. A review of the clinical record failed to reveal an advance directive or documentation that Resident R94 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R95 was re-admitted to the facility on [DATE], with diagnoses that includes ALS, tracheostomy, and depression. A review of the clinical record failed to reveal an advance directive or documentation that Resident R95 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R96 was admitted to the facility on [DATE], with diagnoses that include diabetes, and muscle weakness. \ A review of the clinical record failed to reveal an advance directive or documentation that Resident R96 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R206 was admitted to the facility on [DATE], with diagnoses that include dementia (loss of thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), diabetes, and high blood pressure. A review of the clinical record failed to reveal an advance directive or documentation that Resident R206 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R207 was admitted to the facility on [DATE], with diagnoses that include Parkinson ' s disease (affects movement of muscles often seen with tremors, shaking), dysphagia, and abdominal hernia (weakening of abdominal muscle causing a bulge). A review of the clinical record failed to reveal an advance directive or documentation that Resident R207 was given the opportunity to formulate an Advanced Directive. A review of the clinical record indicated Resident R208 was admitted to the facility on [DATE], with diagnoses that include diabetes, atrial fibrillation (abnormal heartbeat) and nicotine dependence. A review of the clinical record failed to reveal an advance directive or documentation that Resident R208 was given the opportunity to formulate an Advanced Directive. 395692 Page 3 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 2/22/2024, at 1:44 p.m. the Social Services Assistant E2 stated she confused the POLST with Advance Directives, confirming Residents (Resident R1, R10, R38, R39, R57, R68, R70, R76, R77, R78, R79, R87, R94, R95, R96, R206, R207, R208), were not afforded the opportunity to formulate Advance Directives upon admissions and periodically during their stay in the facility. During an interview on 2/22/24, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to afford the residents the opportunity to formulate Advance Directives upon admissions and periodically during their stay in the facility. 28 Pa. Code: 201.29(b)(d)(j) Resident rights. 395692 Page 4 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, it was determined that the facility failed to assess for the use of an assistive device for one of eight residents (Resident R54). Residents Affected - Few Findings include: Review of Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact 8-12: moderately impaired 0-7: severe impairment Review of the clinical record indicated Resident R54 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/3/24 included the diagnoses of Parkinson's disease (neuromuscular disorder causing tremors and difficulty walking) and physical debility. Section GG: Functional Abilities and Goals indicated that Resident R54 utilized a manual wheelchair. Section C: Cognitive Patterns, Question C0500 BIMS Summary Score revealed a score of 12. During an interview on 2/20/24, at 1:18 p.m. Resident R54 stated that he was frustrated that the physical therapy department would not allow him to use his motorized wheelchair. Review of the clinical record on 2/20/24, at 1:40 p.m. failed to reveal an assessment for Resident R54's ability to use a motorized wheelchair. During an interview on 2/23/24, at 12:07 p.m. the Rehabilitation Director Employee E18 confirmed that Resident R54 was not assessed for the use of a power wheelchair. Rehabilitation Director Employee E18 stated that at the time of admission (approximately eight months previous) Resident R54, his family, and medical providers had decided that a motorized wheelchair was not appropriate. Rehabilitation Director Employee E18 confirmed that after admission Resident R54 has requested the use of his motorized wheelchair, but that no further assessment had been completed to reflect the change in Resident R54's wishes and his level of functioning. During an interview on 2/26/24, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to assess for the use of an assistive device for one of eight residents. 28 Pa. Code 211.12(d)(3)(5) Nursing services. 395692 Page 5 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for six of nine residents reviewed (Residents R10, R14, R46, R54, R68, and R70). Residents Affected - Some Findings include: The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it ' s untreated for long periods of time, you can damage your nerves, blood vessels, tissues and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds. Review of the facility provided education Diabetic Management indicated if the blood sugar falls below 70, call physician for guidance. and if you have a sliding scale order with parameters that state to call the MD (doctor) at certain high or low levels you must call the MD and document their response. Review of the facility policy Hypoglycemia Management reviewed 1/13/23 and 1/2/24, indicated the healthcare provider may designate and individual parameter for hypoglycemia, if so use this number (along with clinical symptoms) to determine whether interventions are necessary. For asymptomatic and responsive residents with blood glucose reading less than 70 (or ordered parameters) give the resident an oral form of rapidly absorbed glucose (juice, soda), recheck blood glucose in 15 minutes. Review of the facility policy Change of Condition reviewed 1/13/23 and 1/2/24, indicated it is the policy of the facility to inform residents, physician/providers. and resident representative of a change in resident's condition. Evaluate any changes noted through direct observation. Obtain a complete set of vital signs. Obtain an other data necessary for a complete evaluation (blood glucose fingerstick, neurochecks, etc.). Follow up by the licensed staff of the change in condition should continue for a minimum of 72 hours following the onset of the change, or as ordered by the physician. Follow up is to include a minimum: full set of vital signs, and an assessment with updates regarding the change in condition and observations. 395692 Page 6 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0684 Level of Harm - Minimal harm or potential for actual harm Review of the facility policy Charting and Documentation Policy Statement reviewed 1/13/23 and 1/2/24, indicated all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc. must be documented in the resident's clinical records. All incidents, accidents, or changes in the resident's condition must be recorded. Residents Affected - Some Review of the clinical record indicated Resident R10 was admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and depression. Review of Resident R10' s Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 1/9/24, indicated the diagnoses remain current. Review of a physician ' s order dated 6/21/23, glucose monitoring before meals and at bedtimes. Further review of a physician order dated 11/20/23, indicated to inject Determir (long-acting type of insulin that works slowly, over about 24 hours) 7 units one time a day. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 2/17/24, at 10:09 p.m. CBG was noted to be 402. On 2/18/24, at 4:57 p.m. CBG was noted to be 434. On 2/19/24, at 3:54 p.m. CBG was noted to be 447. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan revised 1/9/24, failed to indicate interventions for diabetes, hyperglycemia, or hypoglycemia. Review of a clinical record indicated Resident R14 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, dementia (group of symptoms affecting memory, thinking and social abilities), and obesity. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician ' s orders dated 3/17/23, indicated blood glucose monitor AC (before meals) and HS (at bedtime), notify Dr is BS (blood sugar) is less than 90 in the AM or greater than 400. Further review of physician's order dated 5/10/23 through 11/22/23, indicated to inject Humalog (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) 4 units two times a day , and 8 units one time a day. Further review of a physician's order dated 11/22/23, indicated to inject Lispro (Humalog) insulin 6 units with meals. An order dated 1/23/24, indicated glargine (long-acting type of insulin that works slowly, over about 24 hours) inject 42 units one time a day. Review of Resident R14's eMAR revealed that the resident's CBG's were as follows: 395692 Page 7 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0684 On 9/10/23, at 5:50 a.m. CBG was noted to be 58. Level of Harm - Minimal harm or potential for actual harm On 9/11/23, at 5:34 a.m. CBG was noted to be 51. On 9/24/23, at 11:08 a.m. CBG was noted to be 403. Residents Affected - Some On 12/15/23, at 8:22 a.m. CBG was noted to be 431. On 1/19/24, at 8:40 a.m. CBG was noted to be 471. On 1/22/24, at 5:46 a.m. CBG was noted to be 82. On 2/3/24, at 6:07 a.m. CBG was noted to be 81. On 2/5/24, at 6:08 a.m. CBG was noted to be 73. A review of Resident R14's eMAR and clinical progress notes indicated the resident was not assessed for hypoglycemia, failed to follow interventions of the care plan, blood sugar was not rechecked, and the physician was not notified of abnormal results. Monitor/document/report as needed signs and symptoms of hypo-/hyperglycemia A review of Resident R14's care plan dated 10/12/13,diabetes medication as ordered by doctor. Monitor/document/report for side effects and effectiveness. Review of the clinical record indicated Resident R46 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, dementia, and difficulty swallowing. Review of the MDS dated [DATE], indicated the diagnoses remain current. Review of physician orders dated 10/4/22, glucagon 1mg injection as needed for symptomatic hypoglycemia. Further review of a physician's order dated 1/24/23, indicated Levemir (Determir) inject 25 units one time a day. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 11/8/23, at 3:54 p.m CBG was noted to be 478. On 12/5/23, at 4:39 p.m. CBG was noted to be 66. On 2/9/24, at 5:00 p.m. CBG was noted to be 415. Review of Resident R46's eMAR and clinical progress notes indicated the resident was not assessed for hypo-/ hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/22/20, indicated diabetes medications as ordered by doctor, monitor/document for side effects and effectiveness. Fasting serum blood sugar as ordered by doctor. 395692 Page 8 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0684 Monitor/document/report to MD as needed for signs and symptoms of hypo-/hyperglycemia. Level of Harm - Minimal harm or potential for actual harm Review of the clinical record indicated Resident R54 was admitted to the facility on [DATE], with diagnoses that included diabetes, difficulty swallowing, and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). Residents Affected - Some Review of the physician's orders revealed the following orders: On 8/15/23 through 10/17/23, Humalog insulin per sliding scale 120 or greater inject 12 units one time a day. On 10/17/23 through 11/2/23, Humalog insulin 10 units one time a day. On 11/2/23 through 11/14/23, Humalog insulin 15 units one time a day. On 11/14/23 through 1/31/24, Humalog insulin 20 units before meals. On 1/31/24, Humalog insulin 20 units before meals, hold is blood sugar is less than 120 or not eating. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 10/8/23, at 8:24 p.m. CBG was noted to be 411. On 10/11/23, at 8:11 p.m. CBG was noted to be 414. On 10/27/23, at 3:37 p.m. CBG was noted to be 525. On 10/29/23, at 4:35 p.m. CBG was noted to be 436. On 10/29/23, at 9:31 p.m. CBG was noted to be e 413. On 11/2/23, at 12:06 p.m. CBG was noted to be 401. On 12/7/23, at 9:29 p.m. CBG was noted to be 454. On 1/27/24, at 4:56 p.m. CBG was noted to be 415. On 2/4/24, at 9:14 p.m. CBG was noted to be 402. On 2/7/24, at 6:22 p.m. CBG was noted to be 467. On 2/7/24, at 9:54 p.m. CBG was noted to be 436. On 2/14/24, at 9:05 p.m. CBG was noted to be 436. On 2/18/24, at 4:24 p.m. CBG was noted to be 420. On 2/18/24, at 8:43 p.m. CBG was noted to be 406. Review of Resident 54's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 4/19/23, indicated to diabetes medication as ordered by doctor, monitor/document for side effects and effectiveness. Monitor/document/report to MD as needed for signs 395692 Page 9 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0684 and symptoms of hyperglycemia. Level of Harm - Minimal harm or potential for actual harm Review of the clinical record indicated Resident R68 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, and hyperglycemia. Residents Affected - Some Review of Resident R68's MDS dated [DATE], indicated the diagnoses remain current. Review of a physician ' s order dated 11/3/23, indicated to inject Determir insulin 28 units one time a day (long-acting type of insulin that works slowly, over about 24 hours). Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 12/5/23, at 5:50 a.m. CBG was noted to be 58. On 12/6/23, at 11:09 p.m. CBG was noted to be 31. Blood glucose was not rechecked until 12/7/23, at 5:07 a.m Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hypo-/hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed dates. Review of the care plan dated 7/20/22, indicated to give diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report to MD as needed signs and symptoms of hypoglycemia. Anticipate and meet the resident's needs. Review of the clinical record indicated Resident R70 was re-admitted to the facility on [DATE], with diagnoses that included diabetes, high blood pressure, and obesity. Review of Resident R70' s MDS dated [DATE], indicated the diagnoses remain current. Review of a physician ' s order dated 1/31/24, indicated Levemir (long-acting type of insulin that works slowly, over about 24 hours) 30 units two times a day. Review of the clinical record electronic Medication Administration Record (eMAR) revealed that the resident's CBG's were as follows: On 2/2/24, at 8:51 a.m. CBG was noted to be 402. On 2/3/24, at 8:01 a.m. CBG was noted to be 433. On 2/3/24, at 8:52 p.m. CBG was noted to be 404. On 2/4/24, at 9:44 p.m. CBG was noted to be 439. Review of Resident's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above 395692 Page 10 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0684 listed dates. Level of Harm - Minimal harm or potential for actual harm Review of the care plan failed to indicate interventions for diabetes, hyperglycemia, or hypoglycemia prior to 2/8/24. Residents Affected - Some During an interview on 2/23/24, at 9:00 a.m. Licensed Practical Nurse (LPN) Employee E3 stated its a judgement call on when they would notify the doctor. If the blood glucose was low they would give juice or snack, monitor, check on the resident every hour and double check the fingerstick if the resident is symptomatic. If the blood glucose was outside of the ordered parameters they would call the doctor, give the ordered amount of insulin, and if symptomatic they would call the doctor. During an interview on 2/23/24, at 9:05 a.m. LPN Employee E4 stated for blood sugars over 400, they would check the parameters, call the provider for orders, assess the resident, recheck the blood glucose in 15-20 minutes. If the blood sugar was less than 60 they would offer a snack, and call the doctor if snack was not successful. During an interview on 2/23/24, at 9:09 a.m. LPN Employee E5 stated she would check the resident's orders for parameters. If blood glucose was less than 60-70, she would give juice or snack, report the incident to the Registered Nurse (RN) supervisor, and recheck the blood glucose in 30 minutes. For blood sugars over 150, she would report it to the RN supervisor if it was beyond the sliding scale. She would give the ordered dose on insulin, recheck blood glucose in 30 minutes and if ot responding to the medication she would notify the doctor. During an interview on 2/23/24, at 9:15 a.m. LPN Employee 6 stated for blood sugars less than 70 they would give snack or glucose gel. For blood sugars over 400, they would notify the doctor, complete an assessment, document in the vital signs and progress notes During an interview on 2/23/24, at 12:00 p.m. LPN Employee E7 stated for blood glucose less than 60-70, they would give glucose gel, call the doctor, monitor vital signs, and recheck the blood glucose in 15-20 minutes. If blood glucose was over 400 they would call the doctor, administer insulin and monitor vital signs. During an interview on 2/23/24, at 1:30 p.m. the Director of Nursing confirmed the facility failed to notify the doctor of a change in condition related to blood glucose, failed to follow the care plan interventions, and failed to recheck blood sugars for Residents R10, R14, R46, R54, R68, and R70. 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. 395692 Page 11 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications and medical supplies were properly stored and/or disposed of in one of two medication rooms (100-Unit medication room ). Findings include: Review of the facility policy Storage of Medications dated 1/2/24, indicated medications are and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. During an observation of the 100-Unit medication room on 2/21/24, at 12:58 p.m. the following was observed: (2) opened bottles of resident specific Dakins solution. (1) liter bag of NSS, with no overwrap. (9) vials of ceftriaxone, with an expiration date of 05/2023, stored in a drawer with luau party supplies. (1) urethral catheter, with an expiration date of 6/28/23. (4) intravenous fluid administration sets, with an expiration date of 10/13/23. (1) Sterile Foley Cath Insertion Kit, opened, with items removed. (1) Syringe with an expiration date of 10/11/23. (6) External catheters with an expiration date of 5/28/22. (6) External catheters with an expiration date of 9/28/22. During an interview on 2/21/24, at 1:15 p.m. LPN Employee E10 confirmed the above observation. During an interview on 2/23/24, at approximately 2:00 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that medical supplies were properly stored in one of two medication rooms. 28 Pa. Code: 201.14 (a) Responsibility of licensee. 28 Pa. Code: 201.18 (b)(1)(e)(1) Management. 28 Pa. Code: 211.9 (a)(1) Pharmacy services. 28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services. 395692 Page 12 of 13 395692 02/26/2024 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0941 Level of Harm - Potential for minimal harm Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on effective communication. Residents Affected - Many Findings include: Review of the Facility Assessment dated 1/9/24, indicated that staff competencies would include required training based on regulations. Review of facility provided education documents failed to include evidence of training for staff on effective communication. During an interview on 2/23/24, at 11:57 a.m. the Director of Operations Employee E17 confirmed the above missing education. During an interview on 2/26/24, at approximately 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to provide training on effective communication. 28 Pa Code: 201.14 (a) Responsibility of licensee. 28 Pa Code: 201.18 (b)(1) Management. 28 Pa Code: 201.20 (a)(c) Staff development. 395692 Page 13 of 13