Health inspection·March 27, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident records, observation, and staff interview it was determined that the facility failed to uphold the privacy and dignity of one of nine residents reviewed that receives medications (Resident R77). In addition, the facility failed to uphold the resident ' s rights to voice grievances without fear of retaliation for three of nine residents reviewed (Resident R301, R302, R303). Findings include: Review of the facility policy Resident Rights last reviewed 1/6/25, indicated residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has the right to be treated with respect and dignity and care for each Resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each Resident ' s individuality, thus protecting and promoting the right of the Resident. The Resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. A review of the facility policy Administration Procedure for All Medications:, last reviewed 1/6/25, indicated that privacy is provided for the resident during administration of medications and all 5 Rights should be followed during medication administration (Right Resident, Right Drug, Right Dose, Right Route of Administration and Right Time). Review of the clinical record revealed Resident R77 was admitted on [DATE], with diagnoses that included diabetes (body has troubling controlling blood sugar), high blood pressure, muscle weakness and history of falling. During an observation on 3/26/25, at 10:08 a.m. Resident R77 was administered medications, both pills and liquid, in the dining hall as she was awaiting the Resident Group meeting to start. During an interview on 3/26/25, at approximately 11:00 a.m. Licensed Practical Nurse Employee E2 confirmed that Resident R77 did not have an order or care plan to receive her medications anywhere but in her room in private. During an interview on 3/27/25, at 9:30 a.m. Registered Nurse Employee E3 confirmed that Resident R77 did not have an order or care plan to receive medications anywhere but in her room in private. During an interview on 3/26/25, between 10:00 a.m. and 11:00 a.m. Resident R301 stated they feel discriminated against because of some issues he had in the past and they feel that their needs are not Page 1 of 3 395692 395692 03/27/2025 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few being handled properly and he has fear of not being assisted or given the chance to find alternate transportation for an event he needs to attend. The resident requested to remain anonymous. During an interview on 3/26/25, between 10:00 a.m. and 11:00 a.m. Resident R303 did not want to be interviewed until they confirmed that their name was not going to be mentioned when the state surveyor discussed the issue with the facility. They stated they are afraid to speak up against the facility staff in fear of retaliation. They stated they did not want the staff to come back and not take care of them. Their concern was that their call bell would be ignored, resident care not given, or staff being mean to them. This resident requested to remain anonymous. During an interview on 3/27/25, at 12:30 p.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to uphold the privacy and dignity of one resident receiving medications not in private and failed to ensure resident ' s do not feel retaliated against when voicing complaints or grievances. 28 Pa Code: 201.29 (i) Resident rights. 395692 Page 2 of 3 395692 03/27/2025 Transitions Healthcare Washington PA 90 Humbert Lane Washington, PA 15301

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for one of five residents. (Resident R50). Findings include: Review of the facility policy, Behavior Health Program dated 1/6/25, indicated; The physician will utilize giving psychotropic medications only when necessary to treat a specific diagnosed and documented condition. Review of Resident R50's admission record indicated she was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident R50's Minimum Data Set (MDS- periodic assessment of care needs) assessment dated [DATE], included diagnoses of quadriplegia (a condition that causes partial or total loss of sensation and movement in the torso and all four limbs), chronic respiratory failure (a condition where oxygen and carbon dioxide are unable to adequately exchange in the lungs), and tracheostomy(a surgical procedure where an incision is made in the trachea to relieve an obstruction to allow breathing and prevent buildup of secretions. Review of Resident R50's MDS, failed to include documentation of depression diagnosis. Review of Section N: Medications revealed Resident R50 received antipsychotic medications in the seven days prior to the assessment. Review of a physician order dated 8/8/23, indicated Resident R50 received Mirtazapine (an anti-depressant medication) 15 mg once per day at bedtime for depression. Review of a physician order dated 1/25/24, indicated Resident R50 received Trazodone (an anti-depressant medication) 100 mg once per day at bedtime for depression. Review of a physician order dated 3/5/25, indicated Resident R50 received Duloxetine (an anti-depressant medication) 60 mg once per day for depression. Review of Resident R50's care plan for the use of anti-depressant medication initiated 8/9/23, indicated Resident R50 received psychotropic medication related to depression. During an interview 3/27/25, at approximately 1:00 p.m. Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain that each resident's drug regimen was free from unnecessary drugs used without adequate indications for use for one of five residents. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.2(a)(c) Physician services. 28 Pa. Code: 211.9(a)(1)(d)(k) Pharmacy services. 28 Pa. Code: 211.12(c)(d)(5) Nursing services. 395692 Page 3 of 3