Health inspection·June 1, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review, staff and resident interviews, it was determined that the facility failed to ensure the environment meets the individual needs of each resident by ensuring the call bell was reach of the resident for one of 16 residents reviewed (Resident 4). Residents Affected - Few Findings include Review of Resident 4's clinical record on May 30, 2023, revealed diagnoses including chronic atrial fibrillation (a longstanding, chaotic, and irregular heart beat), epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), and intervertebral disc disorders with myelopathy lumbar region (a medical condition of the middle/lower spine that results in pressure within the spinal cord). Review of Resident 4's Annual Minimum Data Set (MDS - periodic assessment of resident care and service needs) Assessment reference date of April 25, 2023, revealed in section, G0110. Activities of Daily Living (ADL) Assistance, subsection, B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) was coded as Resident 4 needing limited assistance of one person physically assisting. Further, subsection, E. Locomotion on unit - how resident moves between locations in his/her room and adjacent corridor on same floor was coded as Resident 4 needing limited assistance of one person physically assisting. Observations of Resident 4's room on May 30, 2023, at approximately 11:30 AM, revealed that Resident 4 was sitting in a recliner chair located beside Resident 4's bed. Observations revealed that Resident 4's call bell was on the floor behind Resident 4's chair. During an interview with Resident 4 on May 30, 2023, at 11:31 AM, Resident 4 requested to be transferred from the chair to the bed. At approximately 11:40 AM, staff entered the room to assist Resident 4 to the bed. Observations at 11:42 AM, revealed Resident 4 was in bed. Further, it was observed that Resident 4's call bell was located behind Resident 4's chair. Observations of Resident 4's room on May 31, 2023, at approximately 2:05 PM, revealed that Resident 4 was sitting in their recliner chair located beside their bed with Resident 4's call bell placed on the opposite side of the bed. Resident 4's walker was observed to be on the opposite side of the room by the door, not within reach of the Resident. During a staff interview on June 1, 2023, at approximately 10:50 AM, Nursing Home Administrator revealed it was the facility's expectation for call bells to be in reach of a resident. Page 1 of 22 395915 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0558 Pa. code 211.12(d)(1) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395915 Page 2 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on Resident Council Minutes review, policy review, and staff interview, it was determined that the facility acted on grievances identified during two of three Resident Council Minutes reviewed (January 2023, February 2023). Residents Affected - Some Findings include: Review of facility policy, titled OPS-373 Resident/Family Group and Response last reviewed January 20, 2023, revealed Procedure, subsection 3 stated, The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Review of Resident Council Meeting minutes from January 30, 2023, revealed residents had shared concerns with nursing services. Concerns identified in the meeting minutes stated, Nursing: Concerns about agency aides not caring about their [the residents'] care. They feel weekend care is terrible. They feel there is no communication between nursing staff which leads to no proper care. Review of Resident Council Meeting minutes from February 22, 2023, revealed residents had concerns with nursing services. Concerns identified in the meeting minutes stated, Nursing: Concerns about agency aides not caring about their care. They [Residents in attendance] feel weekend care is terrible. Call lights not being answered for long periods of time. During a staff interview on May 31, 2023, at approximately 1:30 PM, a request was made for the facility's response to the January 2023 and February 2023 Resident Council Meeting concerns regarding concerns. During a staff interview on June 1, 2023, Nursing Home Administrator revealed there was no documented response to the concerns raised during the January 2023 and February 2023 Resident Council Meetings. 28 Pa code 201.18(c)(1) Management 395915 Page 3 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident the right to formulate an advance directive and facilitate follow-up procedures to provide information to the resident or resident representative at an appropriate time for two of 19 residents reviewed (Residents 31 and 34). Findings Include: Review of facility policy, titled CLIN-130 Advanced Directive and Advanced Care Planning (end of life) with a revision date of June 5, 2017, revealed It is the policy and intent of the Facility to inquire, obtain, or provide, the completion of advanced directives for the purpose of prospectively identifying a healthcare decision maker, clarifying treatment preferences and developing individualized goals of care near the end of life .The facility is required to provide, at the time of a resident's admission, written information concerning the resident's rights to make decisions concerning medical care, including the right to refuse medical or surgical treatment, decline to participate in experimental research and the right to formulate advance directives. Review of Resident 31's clinical record revealed that Resident 31 was admitted to the facility on [DATE], with diagnoses that included epilepsy (seizure disorder) and hypertension (elevated blood pressure). Further review of Resident 31's clinical record revealed no documentation of an advance directive or documentation of facility staff discussion with the Resident and/or Resident Representative regarding the right to formulate an advance directive. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on May 31, 2023, at 1:04 PM, the DON stated he was unable to find Resident 31's advance directive or evidence that Resident 31 or Resident 31's Responsible Party was offered the right to formulate one. Review of Resident 34's clinical record revealed that Resident 34 was admitted to the facility on [DATE], with diagnoses that included dementia and diabetes. Further review of Resident 34's clinical record revealed no documentation of an advance directive or documentation of facility staff discussion with the Resident and/or Resident Representative regarding the right to formulate an advance directive. During an interview with the NHA and DON on May 31, 2023, at 1:04 PM, the DON stated he was unable to find Resident 34's advance directive or evidence that Resident 34 or Resident 34's Responsible Party was offered the right to formulate one. In a follow-up interview with the NHA and DON on June 1, 2023, at 12:07 PM, the NHA stated that advance directive screening is done upon admission during the psychosocial admission assessment and if the Resident does not have an advance directive, the facility will offer to help them formulate one if they wish. The DON stated that when the facility changed owners, the new question regarding advance directives was added to the admission questionaire and Residents who were admitted prior to the change in ownership may have gotten missed being offered the right to formulate one. 395915 Page 4 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0578 28 Pa. Code 201.14 (a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.5 (f) Clinical records Residents Affected - Few 395915 Page 5 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on clinical record review and staff interviews, it was determined that the facility failed to inform/notify the physician regarding a change in resident's physical status for one of 18 residents reviewed (Resident 19). Findings include: Review of Resident 19's clinical record revealed diagnoses that included CVA (CVA - cerebrovascular accident - when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel), left hemiparesis (weakness on one side of the body), obesity (a condition characterized by abnormal or excessive fat accumulation), osteoarthritis (a type of arthritis that affects the joints in your body), Diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), epilepsy (a central nervous system disorder that causes seizures), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and hypertension (elevated/high blood pressure). Review of Resident 19's progress note dated February 8, 2023, at 8:29 PM, read, in part, nursing assistant reported a lump in Resident's groin. Resident felt right lower quadrant with fingers to find lump and stated it's been there for about eight months. Writer palpated middle of right lower quadrant and felt a small lump, firm and non- moveable. Resident denies pain or discomfort from area. Will pass on for further evaluation. Further review of Resident 19's clinical record, including physician regulatory visit progress note dated February 17, 2023, failed to contain documentation addressing the concern with Resident 19' right lower quadrant. During an interview with the Director of Nursing (DON) on June 1, 2023, at 9:30 AM, revealed that the staff member who wrote the progress note stated that she left written notification for the physician to assess the aforementioned area. It was also revealed that there is no documentation that the Physician assessed the area. The DON stated that he informed the Physician on May 31, 2023, and an ultrasound has been ordered. 28 Pa code 211.2(a) Physician Services 28 Pa code 211.12(d)(5) Nursing services 395915 Page 6 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations and resident and staff interview, it was determined that the facility failed to maintain a safe, clean, and home-like environment for three of 33 resident rooms (Residents 19, 23, and 29). Residents Affected - Few Findings include: Interview with Resident 29 on May 30, 2023, at 10:30 AM, revealed that frequently staff disposes of soiled/used briefs in bathroom trash can. Observation in Resident 29's bathroom on May 30, 2023, at 10:30 AM, revealed one used brief was in the bathroom trash can. Observation in Resident 23's room May 30, 2023, at 10:38 AM, revealed the privacy curtain between the door and window beds contained dried brown spots. Observation in Resident 23's room on May 31, 2023, at 10:24 AM, revealed the privacy curtain remained soiled. Observation in Resident 19's room on May 30, 2023, at 11:00 AM, revealed there was one used brief in the trash can to the left of the television inside the Resident's room. During an interview with Employee 6 (Housekeeping District Manager) on May 31, 2023, at 12:48 PM, it was revealed that the facility has one spare privacy curtain, which was hung in Resident 23's room; and the soiled curtain is in the laundry to be washed. It was also revealed that the facility has placed an order for privacy curtains to enable the staff the ability to launder soiled curtains and supply each resident/room with a privacy curtain. During an interview with the Nursing Home Administrator on May 31, 2023 at 1:50 PM, it was revealed that soiled/used briefs shouldn't be disposed of in resident room or bathroom trash cans. It was also revealed that the facility has ordered new privacy curtains for each resident room. 28 Pa. Code 207.2(a) Administration responsibility 395915 Page 7 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observations, review of facility policy, and staff interview, it was determined that the facility failed to provide residents access to grievance forms and failed to post the required information of the Grievance Official for one of two areas identified (Nursing station). Findings include: Review of facility policy, titled OPS - 352 Grievance Policy last reviewed January 20, 2023, revealed section titled, Policy stated, .A Grievance Official will be appointed by the Facility Administrator and that person/position will be posted for identification. Review of subsection 2 of Procedure stated, Grievance forms are located at each nursing station, the receptionists' office and outside the Social Service office . Observations of all resident areas conducted on May 30, 31, 2023, and June 1, 2023, revealed the facility failed to post written information that identified the facility's Grievance Official, as well as the Grievance Official's business mailing and email address and phone number. Observations of the nursing station on May 30, 31, 2023, and June 1, 2023, revealed grievance/concern forms were not available to residents or family members as identified in the facility policy. During a staff interview on June 1, 2023, at approximately 10:50 AM, Nursing Home Administrator (NHA) confirmed that there were no grievance forms available at the nursing station and that the required information of the Grievance Official was not posted. During the interview, the NHA revealed it was the facility's expectation that grievance forms would be available at the nursing station, per policy, and that required Grievance Official information would be posted. 28 Pa code 201.18(b)(2)(3) Management 28 Pa code 201.29(a) Resident rights 395915 Page 8 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on review of facility policy, clinical record review, documentation provided by the facility, resident and staff interview, and resident group interview, it was determined that the facility failed to ensure one of 18 residents reviewed was free of abuse/neglect (Resident 19). Findings include: Review of facility policy, titled Abuse revised January 20,2023, read, in part, facility will immediately report and thoroughly investigate all allegation of mistreatment, neglect, .neglect is the failure to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Obtain written statements for all staff present during and/or involved in incident, Social Worker to monitor residents wellbeing. During resident group interview conducted on May 31, 2023, at approximately 10:00 AM, three of six resident attendees revealed concerns with the treatment received from staff when they have asked for assistance. Further, the three residents reported that, at times, when asking staff for assistance with picking up items, bathing, or incontinence care, staff would respond with statements such as, You're independent, you can do it yourself .You're not my resident [to care for] .That's not my hall .That's not my room . During an interview with Resident 19 on May 30, 2023, at 10:56 AM, the Resident stated that she asked Employee 8 (Nursing Assistant) at approximately 9:50 AM for assistance with toileting, and was told that she would have to wait that Employee 8 was on break. Resident 19 went on to explain that she ended up soiling herself because she couldn't wait, and was very upset and called her daughter. She also stated that Employee 8 assisted her with a shower when she returned from break and felt the Nursing Assistant was rough with her during the shower. When asked to clarify, Resident stated that Employee 8 wasn't gentle while bathing her and she was curt (short, like she was irritated with her) with her. Resident stated again that she was upset about it, especially that she soiled herself. Surveyor informed the Nursing Home Administrator (NHA) of Resident 19's concern on May 30, 2023, at 11:00 AM. During an interview with the NHA on May 30, 2023, at 11:14 AM, it was revealed that the facility was obtaining staff interviews/statements. Review of Resident 19's physician orders documented: shower scheduled for Tuesday and Friday on dayshift, with a start date of April 5, 2023; toilet transfer in the shower room with assistance of two staff members, with a start date of September 1, 2022; and transfers from bed to wheelchair with assistance of one staff member, with a start date of February 13, 2023. Further review of Resident 19's shower task documentation revealed one person physical assistance for shower provided May 30, 2023. During an interview with the Director of Nursing (DON) on June 1, 2023, at 9:45 AM, it was revealed that he has had several concerns from other resident regarding Employee 8's bed side manner. The DON expressed the opinion that Employee 8 provides good care, however, she does come across as being short or curt with residents; and has been counseled previously regarding customer service. It was 395915 Page 9 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some revealed that the facility started an investigation of neglect and had submitted an event report into the state system, and that the investigation is ongoing. It was revealed that Employee 8 has been suspended during the investigation process. DON stated that he received a call from Resident 19's daughter on May 30th, 2023, at approximately 10:00 AM and was told that Resident 19 required assistance that she soiled herself. At that time, DON called Employee 3 (Unit Manager) to inform of the same, and Employee 3 in turn informed Employee 9 (Nursing Assistant) who was providing care to another resident. It was also revealed that Employee 8 told Resident 19 to put her call bell on and another staff member could assist her to the restroom, which Resident 19 didn't do. Employee 8 returned from break and provided Resident 19 with incontinence care and assistance with a shower. During the aforementioned interview with the DON on June 1, 2023, DON recalled one specific resident, Resident 106, who had a concern with Employee 8. Review of Resident 106's clinical record revealed Resident 106 resided at the facility between October 23, 2022, to November 17, 2023. Review of facility grievance logs revealed no grievance pertaining to Resident 106 and Employee 8 was filed. A request was made for any investigation regarding Resident 106's concern with Employee 8; however, during a staff interview on June 1, 2023, at approximately 12:00 PM, DON revealed that the facility did not have any documented investigation. Review of Employee 8's personnel file revealed: counseling February 16, 2023: verbal warning related to resident grievance communicating in a mean tone, Employee 8 stating to resident that she wouldn't help to get resident up, and was rough during care. Employee 8 was instructed to communicate with residents in such a way that supports dignity and well-being, and not to make assumptions about resident needs/wants. Review of the document revealed it contained an area for, Employee Signature, which was blank. Upon providing Surveyors with a copy of the document, DON stated that Employee 8 refused to sign the document. During an interview with the DON on June 1, 2023, at 12:07 PM, it was revealed that the expectation is that a staff member would communicate with other team members regarding resident care needs prior to leaving for break, and would communicate with residents in a dignified manner. During interview with Nursing Home Administrator and DON on June 1, 2023, at 12:12 PM, surveyor revealed concern with staff approach based on grievance log submissions, resident interviews during initial pool process, and resident group meeting; and lack of follow-up with resident concerns based on resident interviews. No additional information was provided. 28 Pa. code 201.14(a) Responsibility of Licensee 28 Pa. code 201.18(b)(1) Management 28 Pa. Code 201.29(a) Resident rights, 10/1/1998 edition 28 Pa. Code 211.10(d) Resident care policies 395915 Page 10 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0600 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 395915 Page 11 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident's plan of care for three of 19 residents reviewed (Residents 10, 19, and 34). Residents Affected - Some Findings include: Review of Resident 10's clinical record revealed diagnoses that included Alzheimer's Disease and congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should). Review of Resident 10's current care plan revealed a care plan, revised on November 7, 2022, that Resident 10 uses anti-anxiety medication, PRN (as needed) Ativan. Review of Resident 10's physician orders revealed that Resident 10's Ativan was discontinued on March 23, 2023. On June 1, 2023, at 11:08 AM, the Nursing Home Administrator (NHA) provided the surveyor with Resident 10's resolved Ativan care plan, with a resolved date of May 31, 2023. During an interview with the NHA and Director of Nursing (DON) on June 1, 2023, at 12:10 PM, they confirmed that Resident 10's Ativan care plan has been resolved. Review of Resident 19's clinical record revealed diagnoses that included CVA (CVA - cerebrovascular accident - when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel), left hemiparesis (weakness on one side of the body), obesity (a condition characterized by abnormal or excessive fat accumulation), osteoarthritis (a type of arthritis that affects the joints in your body), Diabetes Mellitus (DM - a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), epilepsy (a central nervous system disorder that causes seizures), dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), and hypertension (elevated/high blood pressure). Review of Resident 19's physician orders revealed an order for POSITIONING: left ankle/foot orthotic brace on in AM and off at HS (HS- bedtime). Check skin integrity prior to applying and after removing, dated August 8, 2022. Review of Resident 19's physical therapy evaluation, dated February 15, 2023, revealed prior equipment of left MAFO (MAFO - molded ankle-foot orthosis - bracing provides support to the food and ankle by limiting motion through painful or unstable motion segments). Review of Resident 19's clinical record on May 30, 2023, nurse aid tasks notated POSITIONING: right ankle/foot orthotic brace on in AM and off at HS. Check skin integrity prior to applying and after removing. The same nurse's aid task was recorded the brace was applied May 30, 2023. Review of Resident 19's care plan documented a focus area for at risk for falls related to gait/balance problems, history of CVA, obesity, DM, epilepsy, dementia, with a revision date of June 22, 395915 Page 12 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2022. Interventions included right ankle/foot orthotic brace on in AM and off in PM, check skin for integrity before application of brace and when removing brace, brace must be on for all transfers, dated initiated May 6, 2022, revised on July 7, 2022. Observation of Resident 19 on May 31, 2023, at 11:02 AM, revealed the Resident was wearing an ankle/foot orthotic brace on her left ankle. During an interview with the DON on June 1, 2023, at 10:20 AM, DON revealed he would expect the tasks and care plan to reflect the physician order. The DON further revealed the tasks and care plan were incorrect and were fixed to reflect the appropriate physician order. Review of Resident 34's clinical record revealed diagnoses that included dementia and diabetes. Review of Resident 34's physician orders revealed an order dated December 14, 2022, to place hearing aides in every morning. Observation of Resident 34 on May 30, 2023, at 9:55 AM and 1:24 PM, revealed that Resident 10's hearing aides were not in her ears. Observation of Resident 34 on May 31, 2023, at 9:37 AM, 10:26 AM and 11:35 AM, revealed Resident 34's hearing aides were not in her ears. Review of Resident 34's Medication Administration Record (MAR) dated May 2023, revealed that on May 30, 2023, and May 31, 2023, staff signed off that Resident 34's hearing aides were put in in the morning. Review of witness statement from Employee 2 dated May 31, 2023, revealed that Resident 34's hearing aides are placed every morning but Resident 34 constantly takes them out; so Employee 2 puts them back so she doesn't lose or break them. Review of witness statement from Employee 7 dated May 31, 2023, revealed that Resident 34's hearing aides were placed that morning, but that Resident 34 takes the hearing aides out and places them in her bed. Review of Resident 34's current care plan dated October 6, 2022, revealed that Resident 34 wears bilateral hearing aides. Further review of the care plan revealed no evidence that Resident 34 removes her hearing aides. During an interview with the NHA and DON on June 1, 2023, at 10:26 AM, they confirmed that Resident 34's care plan has since been updated to reflect that Resident 34 often removes her hearing aides. Review of Resident 34's clinical record revealed that Resident 34 had a stage 4 pressure ulcer to her left lateral heel, that resolved as of April 28, 2023. During an interview with Employee 3 on May 30, 2023, at 1:31 PM, she confirmed that Resident 34's pressure ulcers have all healed. Review of Resident 34's current care plan, with a revision date of May 17, 2023, revealed that the left lateral heel was listed on the care plan as a current pressure ulcer. 395915 Page 13 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0657 During an interview with the NHA and DON on June 1, 2023, at 10:26 AM, they stated that Resident 34's care plan has been updated to reflect that the left heel pressure ulcer has resolved. Level of Harm - Minimal harm or potential for actual harm 42 CFR 483.21(b) Comprehensive Care Plans Residents Affected - Some 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(5) Nursing services 395915 Page 14 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, policy review, observations, and resident and staff interviews, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance with these activities of daily living for one of 21 residents reviewed (Resident 12). Residents Affected - Few Findings include: Review of Facility provided policy, titled CLIN-006 Activities of Daily Living with a revision date of March 21, 2016, failed to reveal any standard for assisting dependent residents with shaving. Review of Resident 12's clinical record revealed diagnoses that included diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Observation of Resident 12 on May 30, 2023, at 10:47 AM, had noticeable facial hair present on her upper lip and chin. Immediate interview with Resident 12 at that time revealed that she prefers to have her face shaved and that the facility staff sometimes helps her accomplish that, but not always. Resident 12 revealed that she would prefer if her face was shaved now and hairless. Observation of Resident 12 on May 31, 2023, at 10:34 AM, had noticeable facial hair present on her upper lip and chin. Review of Resident 12 ' s care plan on May 30, 2023, revealed a care plan with a focus area of: Resident 12 has an ADL (Activities of Daily Living) self-care performance deficit, with a revision date of April 10, 2023. Further review of the care plan revealed an intervention of: encourage the Resident to participate to the fullest extent possible with each interaction, with a date initiated of April 7, 2023. Further review of the care plan failed to reveal any specific information regarding Resident 12's ability to shave. Review of Resident 12's Electronic Medical Record (EMR) on May 31, 2023, under the Personal Hygiene section, failed to reveal any instances of Resident 12 refusing assistance with shaving. Further review revealed that Resident 12 was shaved on May 29, 30, and 31, 2023. Interview with the Director of Nursing (DON) on June, 2023, at 12:15 PM, revealed that, when he interviewed the Employee who entered the shaving information in Resident 12's record, it was revealed that the shaving information from May 29, 30, and 31, 2023, was entered in error. The DON also revealed that he would expect the facility staff to assist dependent residents with ADL care including shaving. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services 395915 Page 15 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on document review and staff interview, it was determined that the facility failed to ensure an annual performance review is completed for each nurse aide for two of five nurse aide performance reviews documented (Employees 1 and 2). Residents Affected - Few Findings Include: Review of Employee 1's employee file on June 1, 2023, reviewed that Employee 1 had a hire date of May 1, 2008. Further review failed to reveal an annual performance review within the previous 12 months. Review of Employee 2's employee file on June 1, 2023, reviewed that Employee 2 had a hire date of April 20, 2018. Further review failed to reveal an annual performance review within the previous 12 months. An interview with the Director of Nursing on June 1, 2023, at 1:07 PM, confirmed the annual performance reviews for Employees 1 and 2 were not completed on an annual basis. 28 Pa. Code 201.14 (a) Responsibility of licensee 395915 Page 16 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide pharmaceutical services to accurately acquire, receive, dispense, and administer drugs to meet the needs of each resident (Resident 29). Findings include: Review of Resident 29's clinical record contained diagnoses that included: diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), obesity (being overweight), chronic non-pressure ulcers on right and left legs, and high cholesterol. During an interview with Resident 29 on May 30, 2023, at 10:26 AM, it was revealed that she has missed several doses of medication because it was not available from the pharmacy; specifically her pravastatin (medication use to treat high cholesterol). Review of Resident 29's physician orders included: pravastatin 80 mg at bedtime for hyperlipidemia, with a start date of December 5, 2022. Review of Resident 29's March 2023 Medication Administration Record (MAR- documentation of medication administration): pravastatin 80 mg at bedtime elated to hyperlipidemia documented 9 - see nurses note on May 28th, 2023, (awaiting from pharmacy); an 5- hold see progress note May 29th, 2023 (pending from pharmacy). During an interview with the Director of Nursing (DON) on May 31, 2023, at 1:50 PM, the survey asked for documentation that the physician was notified that the pravastatin wasn't administered to Resident 29 on May 28th and 29th, 2023. During an interview with the DON on June 1, 2023, at 10:20 AM, revealed there is no documentation that the physician was notified of the missed doses of pravastatin. DON was not sure why the pravastatin wasn't available from pharmacy (whether it wasn't ordered by staff, not available from pharmacy, or not delivered). It was also noted that the facility received deliveries from pharmacy twice a day. Review of pharmacy tracking of Resident 29's pravastatin revealed it was reordered and the order processed on May 29, 2023, at 7:13 PM. During an interview with the DON on June 1, 2023, at 12:30 PM, it was revealed that Resident 29's pravastatin should've been reordered prior to May 28th, 2023. 28 Pa. Code 201.14(a) Responsibility of Licensee 28 Pa. Code 211.9(a)(1)(k) Pharmacy services 28 Pa. Code 211.10(c) Resident Care Policies 28 Pa. Code 211.12(d)(5) Nursing Services 395915 Page 17 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observations, clinical record review, and resident and staff interview, it was revealed that the facility failed to ensure that one of 18 residents reviewed received a therapeutic diet per physician order (Resident 29). Findings include: Review of Resident 29's clinical record contained diagnoses that included: diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), obesity (being overweight), chronic non-pressure ulcers on right and left legs, and high cholesterol. Review of Resident 29's physician orders revealed: controlled carbohydrate 2 gram (unit of measure) sodium (low sodium diet) diet regular texture, thin liquids, and large meat/non-starchy entrée portions. Observation in Resident 29's room on May 31, 2023, at 12:35 PM, revealed Resident had completed her meal. Review of the meal ticket on Resident tray failed to document large meat/non-starchy entrée per physician order. Resident stated she wasn't aware that she was to receive large meat/non-starchy entrée portion. During an interview with the Nursing Home Administrator on June 1, 2023, at 9:30 AM, revealed that the tray ticket was updated to include large portion meat/non-starchy entrée portion. Pa code 211.6(a)(b) - Dietary Services 395915 Page 18 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on facility policy review, observations, clinical record review, resident and staff interviews, it was determined that the facility failed to provide and/or have readily available snacks outside of scheduled meal service times in accordance with resident's needs or preferences. Findings include: During resident group interview conducted on May 31, 2023, at approximately 10:00 AM, six of six resident attendees revealed the facility did not provide snacks between meals. One resident stated, They [the facility] stopped [providing snacks] a month or two ago. You can't get them. To which the five remaining resident attendees agreed. During an interview with Resident 29 on May 30, 2023, at 10:24 AM, it was revealed that snacks are no longer available between meals and at bedtime, and that she is diabetic and should have an evening snack. Review of the facility matrix (a grid used to identify pertinent care categories) revealed that there were six residents who receive insulin. Review of facility policy, titled Snacks revised September 2017, read, in part, bedtime snacks will be provided for all residents. Dining Services department will collaborate with the residents, nursing, and management team to identify necessary beverage and snack items to be provided to each resident. The Dining Services department assembles and delivers to each care area, on a daily basis, individually planned snack items and bulk snack items to be offered at bed time. Review of facility meal times revealed: breakfast 8:00 AM, lunch 12:00 PM, and dinner 5:00 PM; resulting in 15 hours between dinner and breakfast. Interview with Employee 3 (Registered Nurse) on May 30, 2023, at 9:50 AM, revealed that snacks are no longer available; especially diabetic snacks. She also revealed that she buys snacks to provide to the residents who are diabetic, because the pantry is not stocked with snacks. Surveyor observed a plastic container with individually wrapped items such as peanut butter, crackers, and granola bars/snack bars. Observation in the nourishment pantry on May 30, 2023, at 9:47 AM, the refrigerator contained several juice cups, two containers of thickened beverages, and several items marked with resident names/room numbers. In the cabinet was: one 11 oz can mandarin oranges with use by date of November 2020 with no resident name or room number; a small basket that contained one individual pack graham crackers and four individual packs of chocolate cookies; one 8 oz can chicken noodle soup; and half jar peanut butter. Interview with Employee 4 (Director of Food Service) on May 30, 3023 at 9:50 AM, revealed that the kitchen doesn't stock the pantry; if a resident wishes to have a snack, nursing will go to the kitchen and ask for it and the kitchen will supply nursing with several individual packed items, such as graham crackers or cookies. Employee 4 also stated that, at that time, there were no residents who received a labeled snack routinely. 395915 Page 19 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation in the nourishment pantry cabinet on May 31, 2023, at 11:08 AM, revealed one 8 oz chicken noodle soup, and 1/2 jar peanut butter. Observation in the nourishment pantry refrigerator on May 31, 2023 at 11:10 AM, revealed two containers of thickened juice; prune juice; as well as several items that were obtained outside of the facility, marked with resident names. Additional interview with Employee 3 on May 31, 2023, at 11:24 AM, revealed that the kitchen doesn't stock the nourishment pantry; if a resident wants a snack, nursing has to go to the kitchen to ask for something, and usually all that's available are graham crackers and soda crackers. It was also noted that labeled snacks are not available if a resident wishes to have an item routinely. Observation in the dry storeroom in the kitchen on May 31, 2023, at 11:41 AM, revealed: one half- filled milk crate with graham crackers; one case of graham crackers; nine individually wrapped chocolate fudge cookies; 3/4 case of individual bags pretzels; one case of individual packaged cheesy corn puffs; and as part of three day emergency supply, one case short bread cookies; and a half of case of soda crackers. Interview with Employee 5 (Dietary District Manager) on May 31, 2023 at 12:30 PM, revealed labeled snacks are delivered to the nourishment pantry at 9:00 AM, 1:00 PM, and 7:00 PM based on resident preference. It was revealed that Dietary doesn't stock the nourishment pantry with additional items; if a resident requests an item or nursing needs something, they can go to the kitchen to ask for it. It was also revealed that the kitchen maintains a stock basic snacks like graham crackers, pudding, yogurt, soda, chips, cookies; items on hand may vary. It was also revealed that the facility doesn't post or provide to nursing a list of items available for snacks; nursing could ask what items are available when they are requesting a snack items(s) for resident(s). Interview with the Nursing Home Administrator on May 31, 2023, at 1:50 PM, revealed that the kitchen doesn't stock the nourishment pantry with snacks. It was then revealed that nursing may not have access to the kitchen once dietary staff leave the facility after supper. It was then revealed that the facility is working on their snack program. 28 Pa. code 211.6 (c)(d) Dietary Services 395915 Page 20 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety and maintain functionality of food service equipment in the kitchen and nourishment pantry. Findings include: Review of facility policy, titled Staff Attire revised September 2017, read, in part, all staff will have their hair off their shoulders, confined in a hair net or cap, and facial hair properly restrained. Review of facility policy, titled Food Storage revised September 2017, read, in part, all foods will be stored in accordance with expiration dates. Observation in the dry store room on May 30, 2023, at 9:33 AM, there was one half full milk crate of individually wrapped graham crackers that wasn't date marked. Additional observation in the dry store room on May 31, 2023, at 11:34 AM, the half full milk crate of individually wrapped graham crackers wasn't date marked. Observation in the walk-in Freezer on May 30, 2023, at 9:35 AM, revealed one half full milk crate of individually wrapped peanut butter and jelly sandwiches wasn't date marked, and one plastic bag with one pie crust wasn't date marked. During an interview with Employee 4 (Director of Food Service) on May 30, 2023, at 9:35 AM, it was revealed that there was a code on the individually wrapped peanut butter and jelly sandwiches; he wasn't sure how to interpret the code, but if needed he could research how to interpret it. Observation at the 3-compartment sink on May 30, 2023, at 9:38 AM, revealed the faucet was unable to be shut off, a solid stream of warm water was noted. Observation at the 3-compartment sink on May 31, 2023, at 11:53 AM, the faucet still had a solid stream of water running from it. During an interview with Employee 4 on May 30, 2023, at 11:53 AM, it was revealed that a work order has been submitted to maintenance several days prior. Observation in the nourishment pantry on May 30, 2023, at 9:47 AM, there were two green pea nutritional shakes with an expiration date of February 2023, marked with a resident name and room number. During an interview with Employee 4 revealed that the aforementioned nutritional shakes are not supplied by the facility, and should be discarded. Observation in the nourishment pantry on May 30, 2023, at 9:49 AM, revealed on the floor to the left and front of the ice machine were two soaked towels, and on the inside of the ice machine revealed the white drip guard contained a black substance. 395915 Page 21 of 22 395915 06/01/2023 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with Employee 4, it was revealed that maintenance is in charge of cleaning the ice machines. Observation on March 31, 2023, at 11:00 AM, the floor drain underneath the ice machine in the nourishment pantry didn't contain an air gap; the pipe from the ice machine and two hoses from the back side of the machine were inside the floor drain, below the grade of the floor. During an interview with Employee 10 on March 31, 2023, at 11:20 AM, it was revealed that the ice machine in the nourishment pantry was serviced on April 27, 2023, and that the machine is serviced every six months. Employee 10 stated he empties the ice, runs chemicals through the machine, and cleans the inside of the bin and removable parts. Observation with Employee 10 on March 31, 2023, at 11:25 AM, the surveyor utilized a clean paper towel and was able to remove the black substance on the top ledge of the white plastic drip cover. Employee 10 initially stated that there was an air gap; however, upon further investigation, Employee 10 revealed that there was one pie and two hoses down inside the floor drain. Surveyor explained that, if the drain were to back up, that the substance could back up into the ice machine. Employee 11 (Maintenance Employee) responded that it makes sense, and Employee 10 stated that it has always been that way. During an interview with the Nursing Home Administrator (NHA) on March 31, 2023, at 1:50 PM, it was revealed that the ice machine had been cleaned and the air gap fixed. Observation in the of tray line service on May 31, 2023, at 11:56 AM, revealed Employee 4 and Employee 5 both had a beard and a mustache, working or tray line and preparing/service food without a facial covering. During an interview with the NHA on May 31, 2023, at 1:50 PM, the surveyor informed of the concerns regarding food items not securely closed in the dry store room, the faucet running at the 3-compartment sink, and expired items in the nourishment pantry. No additional information was provided. During an interview with the NHA on June 1, 2023, at 10:20 AM, revealed the expectation the facial hair should be covered. 28 Pa code 211.6(b)(d) - Dietary Services 395915 Page 22 of 22