Health inspection·August 15, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on resident and staff interviews, clinical record review, and policy review, it was determined that the facility failed to follow the facility policy for reporting an allegation of neglect to the Nursing Home Administrator (NHA) immediately for one of 24 residents reviewed (Resident 5). Findings include: A review of the facility policy, titled Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property, last revised June 14, 2024, stated, any report or suspicion of an incident is to be reported immediately to the charge nurse/supervisor. The Administrator or the Director of Nursing who receives the report are to be notified immediately by the charge nurse/supervisor who receives the report. A review of the clinical record for Resident 5 on August 13, 2024, revealed diagnoses that included obstructive and reflux uropathy (obstructive or functional impediment of urine flow and back-up of urine flow) and bullous pemphigus (a rare autoimmune skin disease that causes blisters to form between the skin's epidermal and dermal layers of the skin). A review of Resident 5's Quarterly MDS (periodic assessment of resident needs) revealed a BIMS (brief interview of mental status) score of 13, indicating Resident 5 is cognitively intact. During an interview with Resident 5 on August 13, 2024, at 9:30 AM, the Resident informed the surveyor that a nurse on night shift August 11, 2024, didn't change her soiled brief. During an interview with Employee 4 (Licensed Practical Nurse) on August 13, 2024, at 9:35 AM, Employee 4 confirmed that Resident 5 stated the same allegation of neglect on the morning of August 12, 2024. Employee 4 stated that she reported the allegation of neglect immediately to the dayshift supervisor on August 12, 2024. During an interview with Employee 5 (Registered Nurse Supervisor) on August 13, 2024, at 10:55 AM, the Employee confirmed being informed about the allegation of neglect that Resident 5 had made to staff on August 12, 2024. Employee 5 was asked if the allegation was reported to the NHA, and Employee 5 confirmed there was no additional reporting of the allegation at the time. On August 13, 2024, at approximately 12:00 PM, the NHA confirmed that he was made aware of the allegation of neglect by Employee 5 on August 13, 2024, and that the facility is in the process of investigating and obtaining statements from staff and Resident 5. Page 1 of 10 395798 395798 08/15/2024 Transitions Healthcare Gettysburg 595 Biglerville Road Gettysburg, PA 17325

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On August 13, 2024, at 1:43 PM, statements were received from the staff working on August 11, 2024, and a statement from Resident 5. Resident 5's statement indicated that she was changed, but staff were slow to change her. Resident 5 required the assistance of two staff. No specific times were provided by Resident 5 indicating a delay. Staff documented care was provided. Staff stated that Resident 5 had frequent episodes of loose stools and was changed frequently with assistance due to those issues. The facility unsubstantiated neglect. During an interview with the NHA on August 14, 2024, at approximately 11:15 AM, the NHA confirmed that policy should have been followed by staff and the allegation of neglect made by Resident 5 should have been reported immediately to the NHA on August 13, 2024. 28 Pa. Code 201.18 (b)(1) Management 28 Pa. Code 211.12(d)(1)Nursing services 395798 Page 2 of 10 395798 08/15/2024 Transitions Healthcare Gettysburg 595 Biglerville Road Gettysburg, PA 17325

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice for three of 27 residents reviewed (Residents 14, 20, and 51). Residents Affected - Few Findings Include: Review of Resident 14's clinical record revealed diagnoses that included type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel resulting in too much sugar circulating in the bloodstream) and history of traumatic brain injury (injury to the brain caused by an external force). Review of Resident 14's physician orders revealed an order for Insulin Glargine, inject 6 units at bedtime for type 2 diabetes, hold for blood sugar level less than 150, starting May 10, 2024. Further review indicated an administration time of 9:30 PM. Review of Resident 14's physician orders also revealed an order to check blood sugar levels before meals and at bedtime, starting May 10, 2024. Further review revealed scheduled times for blood sugar monitoring were 6:30 AM, 11:00 AM, 4:30 PM, and 8:00 PM. Review of Resident 14's July 2024 and August 2024 MARs (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed that a blood sugar level of less than 150 was recorded at 8:00 PM and Resident 14's insulin administration was not held at 9:30 PM on the following dates: July 1-3, 7-8, 10-11, 14-16, 18-23, 25-28, and 31, 2024; and August 3-6 and 9-13, 2024. Further review of Resident 14's July 2024 and August 2024 MARs failed to reveal that blood sugar levels were recorded specifically in correspondence with administration of Resident 51's insulin at 9:30 PM. During an interview with the Nursing Home Administrator (NHA) and Regional Nurse on August 15, 2024, at 1:15 PM, they revealed that they had no additional information regarding the aforementioned insulin administration concern, and that Resident 14's insulin order was updated to include a corresponding blood sugar level check. Review of Resident 20's clinical record revealed diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and hypertension (high blood pressure). Review of Resident 20's clinical record revealed a physician's order for Humalog Kwik Pen Subcutaneous Solution Pen-Injector 200 Unit/milliliters (insulin Lispro) inject as per sliding scale: If 100-150 = 2 units; 151-200 = 3 units; 201-250 = 4 units; 251-300 = 5 units; 301-350 = 6 units; 351-400 = 7 units above 400 call Medical director/nurse practitioner, subcutaneously before meals for diabetes, with a start date of May 20, 2024. Review of Resident 20's May 2024 MAR (Medication Administration Record) revealed the following: On May 23, 2024, at 7:00 AM, Resident 20 had a blood sugar level of 142, and was not administered 395798 Page 3 of 10 395798 08/15/2024 Transitions Healthcare Gettysburg 595 Biglerville Road Gettysburg, PA 17325

F 0658 any insulin. Level of Harm - Minimal harm or potential for actual harm On May 27, 2024, at 7:00 AM, the Resident had a blood sugar level of 146, and was not administered any insulin. Residents Affected - Few On May 28, 2024, at 7:00 AM, the Resident had a blood sugar level of 148, and was not administered any insulin. Review of Resident 20's June 2024 MAR revealed the following: On June 1, 2024, at 7:00 AM, Resident 20 had a blood sugar level of 101, and was not administered any insulin. On June 1, 2024, at 11:00 AM, the Resident had a blood sugar level of 133, and was not administered any insulin. On June 15, 2024, at 7:00 AM, the Resident had a blood sugar level of 100, and was not administered any insulin. On June 17, 2024, at 7:00 AM, the Resident had a blood sugar level of 115, and was not administered any insulin. Review of Resident 20's July 2024 MAR revealed on July 3, 2024, at 7:00 AM, Resident 20 had a blood sugar level of 101, and was not administered any insulin. Review of Resident 20's August 2024 MAR revealed the following: On August 5, 2024, at 7:00 AM, Resident 20 had a blood sugar level of 103, and was not administered any insulin. On August 10, 2024, at 7:00 AM, the Resident had a blood sugar level of 148, and was not administered any insulin. During an interview with the NHA on August 15, 2024, at 11:04 AM, he revealed he would have expected Resident 20 to have been administered insulin as ordered by the physician. Review of Resident 51's clinical record revealed diagnoses that included cerebral infarction (brain injury caused by a lack of oxygen to a group of brain cells) and hemiplegia and hemiparesis following cerebral infarction (inability to move, severe weakness, or rigid movement on either the right or left side of the body). Review of Resident 51's physician orders revealed an order for Trolamine Salicylate External Cream (treats minor aches and pains of the muscles/joints), apply topically to legs every 8 hours as needed for muscle pain, starting March 3, 2023. Observation on August 13, 2024, at 9:50 AM, revealed Resident 51 in bed with his overbed table in front of him. Two small plastic medication administration cups partially filled with a white cream were present on his overbed table. 395798 Page 4 of 10 395798 08/15/2024 Transitions Healthcare Gettysburg 595 Biglerville Road Gettysburg, PA 17325

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Additional observation at 10:04 AM, revealed Employee 1 (Licensed Practical Nurse) inquiring with Resident 51 about the contents of the medication cups on his table. Resident 51 was observed stating that it was Aspercreme (Trolamine Salicylate), that the nurse puts it on but left the cups there, and that he didn't know why the cups were left there. Employee 1 removed the cups from Resident 51's room at that time. During an interview with the Regional Nurse on August 15, 2024, at 11:15 AM, she confirmed that the cream should not have been left in Resident 51's room since he does not self-administer that medication. 28 Pa. Code 201.18(b)(1)(e)(1) Management 28 Pa. Code 211.12(d)(1)(5) Nursing services 395798 Page 5 of 10 395798 08/15/2024 Transitions Healthcare Gettysburg 595 Biglerville Road Gettysburg, PA 17325

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observations, clinical record review, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to prevent pressure ulcers for one of five residents reviewed (Resident 108). Residents Affected - Some Findings Include: Review of facility policy, titled Pressure Ulcer Prevention and Management, revised September 13, 2019, revealed in a section Pressure relief: Elevate/float heels or obtain a device to provide pressure relief. Review of Resident 108's clinical record revealed diagnoses of muscle weakness (weakness in the muscles that makes movement difficult) and diabetes (a chronic disease that occurs when the pancreas does not produce enough insulin). Review of Resident 108's current physician order on August 12, 2024, at 2:35 PM, revealed a physician's order for Blue off-loading boots to B/L (bilateral) heels, with an order date of July 22, 2024. Observation of Resident 108 on August 12, 2024, at 1:48 PM, revealed the Resident was not wearing blue off-loading boots to elevate her heels off of the bed. Observation of Resident 108 on August 13, 2024, at 9:57 AM, revealed the Resident was not wearing blue off-loading boots to elevate her heels off of the bed. Observation of Resident 108 on August 14, 2024, at 10:59 AM, revealed the Resident was not wearing blue off-loading boots to elevate her heels off of the bed. Interview with the Nursing Home Administrator on August 15, 2024, at 11:45 AM, revealed that Resident 108 should have been wearing the off-loading boots at the time of the above observations and the order has been changed to a pressure reducing mattress. 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services 395798 Page 6 of 10 395798 08/15/2024 Transitions Healthcare Gettysburg 595 Biglerville Road Gettysburg, PA 17325

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, clinical record review, policy review, and staff interview, it was determined the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident reviewed for respiratory care (Resident 9). Residents Affected - Few Findings include: Review of facility policy, titled Clin - 157 CPAP/BIPAP, last reviewed March 2024, revealed that when cleaning the system: clean the unit weekly. Review of Resident 9's clinical record revealed diagnoses that included stage 3 chronic kidney disease (when your kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood) and pulmonary fibrosis (a lung disease that occurs when lung tissue become damaged and scarred). During an observation of Resident 9 on August 12, 2024, at 1:57 PM, revealed a CPAP (continuous positive airway pressure) machine and mask sitting on Resident 9's night stand beside their bed, not dated. Review of Resident 9's clinical record revealed a physician's order for CPAP on at bedtime, remove in the AM every shift, and encourage use during naps, with an active date of July 17, 2024. Review of Resident 9's July 2024 and August 2024 MAR (Medication Administration Record) revealed that Resident 9 uses the CPAP daily. Review of Resident 9's clinical record on August 13, 2024, revealed there was no order or documentation indicating the CPAP mask, tubing, filter, and water supply has been cleaned or changed. Review of Resident 9's clinical record on August 15, 2024, at 9:15 AM, revealed new CPAP orders were put in place that included: CPAP/BiPAP - wash headgear/straps, tubing, and humidifying chamber with solution of mild soapy water weekly, and allow to air dry; CPAP/BiPAP filter - weekly, remove from back of device, rinse under running water while squeezing filter to ensure dust is removed. Blot dry with clean towel and place back into machine; CPAP/BiPAP use: check distilled water supply every week. Replace and write date on bottle if: supply depleted, supply not dated, supply dated over 30 days prior, all with an active date of August 20, 2024. During an interview with the Nursing Home Administrator on August 15, 2025, at 11:05 AM, revealed they would have expected Resident 9 to have cleaning orders for their CPAP in place prior to the active date above, and would expect the CPAP to be cleaned weekly. 28 Pa. Code 211.12(d)(5) Nursing services 395798 Page 7 of 10 395798 08/15/2024 Transitions Healthcare Gettysburg 595 Biglerville Road Gettysburg, PA 17325

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observations, product label review, facility policy review, and staff interview, it was determined that the facility failed to store drugs used in the facility in accordance with currently accepted professional principles and the expiration dates for two of three medication carts observed (Annex 1 North medication cart and Annex 1 South medication cart). Findings Include: Review of facility provided policy, Storage of Medications, effective September 2018, revealed, Medication and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Observation of the Annex 1 North medication cart on August 15, 2024, at 9:40 AM, revealed one Ozembic (a prescription injectable medication used to treat type 2 diabetes) that was currently in use and was not labeled with a date that it was opened. The observation at that time also revealed a Levemir pen (a prescription injectable medication used to treat type 2 diabetes) that was unopened, not refrigerated, and was not labeled with the date it had been removed from refrigeration. Also, noted was one Basaglar pen (a prescription injectable medication used to treat type 2 diabetes) that was open and not labeled with a date of opening. Observation of the Annex 1 South medication cart on August 15, 2024, at 9:50 AM, revealed one vial of Lantus insulin (a prescription injectable medication used to treat type 2 diabetes) that was labeled with an open date of June 25, 2024 (51 days prior). A second vial of Lantus insulin was labeled with an open date of July 15, 2024 (31 days prior). Further observation revealed two insulin Aspart pens (a prescription injectable medication used to treat type 2 diabetes) labeled with open dates of July 15, 2024 (31 days prior). Review of Ozembic product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 56 days. Review of Levemir product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 42 days. Review of Basaglar product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 28 days. Review of Lantus product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 28 days. Review of insulin aspart product information on August 15, 2024, revealed that once opened or removed from refrigeration the medication should be discarded after 28 days. Interview with Nursing Home Administrator on August 15, 2024, at 1:35 PM, revealed an expectation that the medication would have been labeled, stored, and disposed of as per the manufacture's guidelines. 395798 Page 8 of 10 395798 08/15/2024 Transitions Healthcare Gettysburg 595 Biglerville Road Gettysburg, PA 17325

F 0761 28 Pa. Code 201.18(b)(1) Management Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395798 Page 9 of 10 395798 08/15/2024 Transitions Healthcare Gettysburg 595 Biglerville Road Gettysburg, PA 17325

F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observations, policy review, clinical record review, and staff interview, it was determined that the facility failed to provide adaptive feeding devices for one of 24 residents reviewed (Resident 59). Residents Affected - Some Findings include: Review of facility provided policy, titled Restorative Adaptive Equipment, with a revision date of March 28, 2016, revealed, Restorative adaptive equipment and assistive devices will be used to promote individual resident functional level and to prevent decline. Review of Resident 59's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and hemiplegia (one-sided weakness caused by brain or spinal cord problems). Review of Resident 59's care plan revealed a focus area of, [Resident 59] is on a therapeutic, mechanically altered diet, with a date initiated of May 29, 2019, and a revision date of January 5, 2022. Further review of this care plan revealed an intervention of, Dycem on side table with meals in dining room, with a revision date of April 23, 2024. Review of Resident 59's current physician's orders on August 12, 2024, revealed an order for Dycem (non-slip rubber mat) in the dining room on table with meals, ordered September 11, 2023. Observation of Resident 59 on August 12, 2024, at 11:29 AM, revealed he was sitting in his room eating lunch and there was no Dycem present. Observation of Resident 59 on August 13, 2024, at 12:04 PM, revealed he was sitting in his room eating lunch and there was no Dycem present. Observation of Resident 59 on August 14, 2024, at 11:46 AM, revealed he was sitting in his room eating lunch and there was no Dycem present. Interview with the Nursing Home Administrator revealed that he would have expected that Resident 59 would have had his ordered adaptive equipment, as ordered, at all meals. 28 Pa Code 211.12(d)(5) Nursing services 395798 Page 10 of 10