Health inspection·May 9, 2024

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. Based on observations, facility policy review and staff interview, it was determined that the facility failed to ensure each resident the right to a dignified existence during meal service for one of one dining rooms observed. Findings Include: Review of facility policy titled Resident Rights, with a revision date of May 5, 2023, revealed Provide meals to all Residents at each table at the same time. Observation in the dining room during lunch on May 6, 2024, at 12:59 PM, revealed Residents 6, 10, 17, 30 and 50 all sitting at a table. Resident 50 was observed to be eating her lunch, while Residents 6, 10, 17 and 30 had not yet been served their lunch. Additional observations revealed the following: At 1:04 PM, Resident 30 was served her lunch. At 1:08 PM, Resident 6 was served her lunch. At 1:12 PM, Resident 17 was served her lunch. At 1:25 PM, Resident 10 was served her lunch. Further observations in the dining room during lunch on May 6, 2024, revealed there were 19 residents total eating in the dining room. Observations revealed all 19 residents were eating their lunch served on trays. Observation in the dining room on May 8, 2024, at 12:28 PM, revealed 22 residents in the dining room. All 22 residents were eating their lunch served on trays. During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on May 8, 2024, at 1:46 PM, the NHA stated that residents should be provided meals at the same time and should not be served meals on trays. 28 Pa Code 201.29(a) Resident Rights Page 1 of 20 395915 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide notice of transfer to the Office of the State Long-Term Care Ombudsman, after a transfer out of the facility, for four of four residents reviewed for hospitalization (Residents 10, 14, 26 and 57). Findings include: Review of Resident 10's clinical record revealed diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should be) and hypertension (high blood pressure). Further review of Resident 10's clinical record revealed that she was transferred and admitted to the hospital on [DATE]. During an interview with the Nursing Home Administrator (NHA) on May 9, 2024, at 10:10 AM, he stated that the Office of the State Long-Term Care Ombudsman was not notified of Resident 10's transfer to the hospital. Review of Resident 14's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and Multiple Sclerosis (MS- a disease in which the immune system eats away at the protective covering of nerves). Further review of Resident 14's clinical record revealed that she was transferred and admitted to the hospital on [DATE]. During an interview with the Nursing Home Administrator (NHA) on May 8, 2024, at 10:37 AM, he stated that the Office of the State Long-Term Care Ombudsman was not notified of Resident 14's transfer to the hospital. Review of Resident 26's clinical record revealed diagnoses that included stage 4 pressure ulcer of the sacrum (injury to skin and underlying tissue resulting from prolonged pressure on the skin; Stage 4 is full-thickness skin and tissue loss) and hypertension (elevated blood pressure). Further review of Resident 26's clinical record revealed that he was transferred and admitted to the hospital on [DATE]. During an interview with the NHA on May 8, 2024, at 10:37 AM, he stated that the Office of the State Long-Term Care Ombudsman was not notified of Resident 26's transfer to the hospital. Review of Resident 57's clinical record review revealed diagnoses included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and ileus (a painful obstruction of the intestine). Further review of Resident 57 clinical record documented admitted to the facility on [DATE], and was transferred to the hospital on February 22, 2024, due to a change in condition. 395915 Page 2 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0623 Level of Harm - Minimal harm or potential for actual harm During an interview with Nursing Home Administrator on May 8, 2024, at 2:00PM with the Nursing Home Administration it was revealed that the facility hadn't notified the State Ombudsman of Resident 57's transfer. 28 Pa. Code 201.14(a) Responsibility of licensee Residents Affected - Some 28 Pa Code 201.18(b)(3) Management 395915 Page 3 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide residents with a copy of the facility's bed-hold policy as a result of a transfer out of the facility for three of four residents reviewed for hospitalization (Residents 10, 14 and 26). Findings Include: Review of facility policy titled Bed Holds and Returns and Therapeutic Leave of Absence, revised September 28, 2022, revealed The Facility will provide information on bed hold requirements to all residents upon admission and again at time of transfer from the Facility. Bed Hold requirements will be included in the Facility admission packet to be reviewed during the admission process and will be considered the first notice of the Facility Bed Holds and Returns policy .The second notice, which details the duration of the bed hold policy, will be issued at the time of transfer. In cases of emergency transfer, notice 'at the time of transfer' means that the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. Review of Resident 10's clinical record revealed diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should be) and hypertension (high blood pressure). Further review of Resident 10's clinical record revealed that she was transferred and admitted to the hospital on [DATE]. During an interview with the Nursing Home Administrator (NHA) on May 9, 2024, at 10:10 AM, he stated that the bed hold notice was not provided to Resident 10 or her responsible party upon her transfer to the hospital. Review of Resident 14's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and Multiple Sclerosis (MS- a disease in which the immune system eats away at the protective covering of nerves). Further review of Resident 14's clinical record revealed that she was transferred and admitted to the hospital on [DATE]. During an interview with the Nursing Home Administrator (NHA) on May 8, 2024, at 10:43 AM, he stated that Resident 14 was an automatic 15 day bed hold under Medicaid, and therefore, was not provided the bed hold notice upon transfer to the hospital. Review of Resident 26's clinical record revealed diagnoses that included stage 4 pressure ulcer of the sacrum (injury to skin and underlying tissue resulting from prolonged pressure on the skin; Stage 4 is full-thickness skin and tissue loss) and hypertension (elevated blood pressure). Further review of Resident 26's clinical record revealed that he was transferred and admitted to the hospital on [DATE]. 395915 Page 4 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0625 During an interview with the NHA on May 8, 2024, at 2:11 PM, he stated that the bed hold notice was not provided to Resident 26 or his responsible party upon his transfer to the hospital. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 201.14(a) Responsibility of licensee Residents Affected - Few 28 Pa Code 201.18(b)(3) Management 395915 Page 5 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 17 residents reviewed (Resident 21 and 32). Residents Affected - Few Finding include: Review of Resident 21's clinical record contained diagnosis that included: dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), Parkinson's disease (disorder of the central nervous system that affects movement), moderate protein calorie malnutrition (moderately-malnourished, protein and energy intake doesn't meet nutritional needs), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality). Further review of Resident 21's clinical record on May 6, 2024, at 12:46 PM documented that Resident 21 had been on Hospice services since November 15, 2023. Review of Resident 21's quarterly Minimum Data Set (MDS- part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated February 7, 2024, failed to documented resident received hospice services. During an interview with the Director of Nursing on May 9, 2024, at 9:05 AM it was revealed the Resident had a physician's order for hospice services with a start date of November 14, 2023, an end date of November 19, 2023, and therefore the order fell off the physician orders. May 9, 2024, at 10:00 AM the facility provided an amended quarterly MDS that included hospice services for Resident 21. During an interview with the Nursing Home Administrator on May 9, 2024, at 11:00PM it was noted the concern regarding hospice services not documented on Resident 21's quarterly MDS dated [DATE]; no further information was provided. Review of Resident 32's clinical record revealed diagnosis that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypoxemia (low levels of oxygen in the blood). Observation of Resident 32 on May 6, 2024, at 11:35 AM and May 7, 2024, at 1:19 PM, revealed that Resident 32 was using oxygen running at 2 liters. Further interview with Resident 32 on May 7, 2024, at 1:19 PM, revealed that she uses oxygen daily. Review of Resident 32's clinical record revealed a nurse's progress note on February 26, 2024, at 9:39 PM, that included the following text: Resident continues on oxygen as previous with no shortness of breath noted; and another note on February 28, 2024, at 9:44 AM, that included the following text: Resident continues on oxygen. Review of Resident 32's quarterly MDS dated [DATE], revealed that Section O0110 C1. Oxygen was marked 'No' indicating that Resident 32 has not used oxygen while a resident during the lookback period. 395915 Page 6 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0641 Level of Harm - Minimal harm or potential for actual harm During an interview with the Director of Nursing and the Nursing Home Administrator on May 9, 2024, at 10:13 AM, revealed that oxygen should have been marked Yes on Resident 32's February 29, 2024, MDS and that a modification MDS has been completed to reflect that. 28 Pa. Code 211.5(f) Clinical records. Residents Affected - Few 28 Pa Code 211.12 (d)(3)(5) Nursing Services. 395915 Page 7 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 17 residents reviewed (Residents 261) Findings include: During an interview with Resident 261 on May 7, 2024, at 9:00 AM it was revealed that she resided in Personal Care prior to hospitalization and then admission into skilled nursing care on May 3, 2024. It was also revealed she had been on hemodialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer preform these functions naturally) for some time, and received hemodialysis on Monday, Wednesday, and Friday outside of the nursing facility. Review of resident 261's clinical record documented diagnoses that included protein calorie malnutrition (moderately-malnourished, protein and energy intake doesn't meet nutritional needs), dependence on hemodialysis, and 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). Review or Resident 261's physician orders failed to document an order for hemodialysis, or care needs surrounding hemodialysis. Review of Resident 261's baseline care plan failed to document hemodialysis and the required care surrounding dialysis. During an interview with the Nursing Home Administrator on May 8, 2024, at 2:00 PM it was revealed that hemodialysis, and resident care surrounding dialysis should've been included in the baseline care plan. 28 Pa. Code 211.12(d) Nursing Services 395915 Page 8 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

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 Based on clinical record review and staff interview, it was determined that the facility failed to ensure one of two residents reviewed for activities of daily living was provided care and services in regard to hygiene and bathing (Resident 32). Residents Affected - Some Finding include: Review of Resident 32's clinical record revealed diagnosis that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypoxemia (low levels of oxygen in the blood). During an interview with Resident 32 on May 6, 2024, at 10:35 AM, she revealed that she didn't get washed up the previous morning (May 5, 2024). Review of Resident 32's clinical record tasks revealed a restorative nursing program for activities of daily living (ADLs) for 15 minutes twice daily, that includes the resident washing and drying her face, hands, and upper body with mid-mod assist from staff and perform her grooming with set-up assist. Review of Resident 32's clinical record revealed a Restorative Program Note written on March 8, 2024, at 4:41 PM, that stated the following: Resident continues to wash and dry her face, hands, and upper body with min-mod assist from staff and perform her grooming with set-up assist. Further review of the ADL task revealed the following dates and times were marked Not Applicable, indicating it was not completed: January 16, 2024 at 11:59 AM, January 27, 2024 at 1:59 PM, January 28, 2024 at 8:37 AM, February 4, 2024 at 7:55 AM, February 10, 2024 at 12:09 PM, February 11, 2024, at 1:39 PM, February 17, 2024 at 1:18 PM, February 18, 2024 at 1:39 PM, February 24, 2024 at 1:39 PM, February 25, 2024 at 12:23 PM, February 26, 2024 at 6:46 AM, March 3, 2024 at 8:23 PM, March 17, 2024 at 12:19 PM, April 6, 2024 at 9:17 PM, April 13, 2024 at 5:06 PM, April 14, 2024 at 9:59 PM, and May 4, 2024 at 1:59 PM. During an interview with the Director of Nursing on May 9, 2024, at 11:32 AM, he stated he did not have an answer as to why the dates listed above were marked Not applicable. The Nursing Home Administrator revealed he would have expected the resident's ADL tasks to have been completed. 28 Pa code 211.12(d)(1)(5) Nursing services 395915 Page 9 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on resident interviews, staff interviews, and facility document review, it was determined that the facility failed to provide an ongoing activities program designed to meet the physical, mental and psychosocial well-being for five out of five residents who attended group for Resident Council (Resident 2, 13, 39, 51, and 260). Residents Affected - Some Findings include: An interview with Employee 3 on May 7, 2024, at 11:30 AM, revealed that the facility only has one activity staff member who works Monday through Friday, and that they do not hold activities for residents on weekends. Interviews with resident's during a group interview on May 8, 2024, at 9:00 AM, revealed the facility does not have any activities held on weekends for the residents, that scheduled activities sometimes get cancelled, and that the resident's feel the activity director needs help. Review of the facility's Resident Council Meeting Minutes from March 2024 revealed the following comments regarding activities: Activities have gone downhill. The activities director has not been here, residents are left alone in dayroom. Aides are in the room, on their phone. Left to watch movies. Can we get volunteers? No activities have been done in a month. Review of the facility's Resident Council Meeting Minutes from April 2024 revealed the following comments regarding activities: Activities director needs help. Residents left in day room all the time with movies on. Would like to have volunteer program. More outdoor activities/areas for outdoor use. Review of the facility's Activity Calendar for March 2024, April 2024, and May 2024 revealed there are no activities scheduled on the calendars for Saturdays or Sundays. During an interview with the Nursing Home Administrator on May 9, 2024, at 10:08 AM, he confirmed there are no activities scheduled on weekends, and that the Activity Director works from Monday through Friday. 28 PA Code 201.29 (j) Resident Rights 28 PA Code 211.10 (d) Resident Care Policies 395915 Page 10 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on review of the dietary extension sheets (guidelines as to what foods should or should not be served for specific therapeutic diets), the Diet Type facility report and staff interview it was determined that the facility failed to provide a therapeutic diet per physician's order, for four residents on a Renal/ low potassium diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balance in the body in individuals who's kidneys don't function as they should or who receive treatments to remove excess water, solutes and toxins from the blood due to kidney failure) and 18 residents on a Consistent Carbohydrate diet (CCD- meals are planned to provide a consistent amount of carbohydrates day to day.) out of 22 residents reviewed on a therapeutic diets. Residents Affected - Some Findings include: On May 8, 2024, review of facility report Diet Type, printed May 8, 2024; documented the following therapeutic diet were prescribed: eighteen residents were ordered consistent carbohydrate diet, and four residents were ordered a renal/low potassium. The in house census on May 8, 2024, was 55 residents. Review of extension sheets (a guide as to what items are t0 be served each meal basted on diet order) documented the following diets: regular, dysphagia advanced (bite sized foods that are moist), and puree (very smooth, crushed, of blended food). No therapeutic diets were documented on the extension sheets. Review of facility diet manual, Maryland Department of Health and Mental Hygiene Diet Manual for Long Term Care Residents, revised 2014, read, in part, low potassium diet should avoid the following foods and beverages: bananas, prunes and prune juice, orange Juice, baked potatoes and sweet potatoes, tomatoes, tomato juice, vegetable juice. Liberalized Renal Diet follow low potassium guidelines, limit obviously salted foods/meats: sausage, bacon, scrapple, ham, chipped beef, corned beef, hot dogs, canned meats, potato chips, salty snack foods, pickles, olives, sauerkraut. Further review of the facility diet manual read, in part, a CCD diet is designed for residents with 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). Meals are planned to provide a consistent amount of carbohydrates day to day. Carbohydrates are distributed consistently per three meals and include an evening snack. Often portions of regular desserts are small so that the menu doesn't exceed the allowed amount of carbohydrates or calories. During an interview with Employee 5, Food Service Director on May 7, 2024, at 2:30 PM it was revealed that the facility doesn't offer a Renal, or CCD diet and therefore the therapeutic diet isn't documented on the extension sheets. Surveyor informed Employee 5 that there are physician orders for Renal, and CCD diets. Employee 5 stated that tomato products and pork products are limited on a renal diet, and the CCD diets receive sugar free jelly and maple syrup, and a sugar substitute. It was also noted that these restrictions would be verbally communicated to the dietary staff. During an interview with the Nursing Home Administrator on May 8, 2024, at 2:00 PM it was revealed that the facility should follow physician ordered therapeutic diets, and facility approved therapeutic diets should be documented on menu extension sheets as a guide for dietary personnel to provide 395915 Page 11 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0692 appropriate menu items for each physician prescribed diet. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa Code 211.6(a) - Dietary Services Residents Affected - Some 395915 Page 12 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

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, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for four of four residents reviewed for respiratory care (Residents 14, 31, 32 and 111). Residents Affected - Some Findings Include: Review of facility policy titled Aerosol Therapy, with a revision date of Mach 21, 2016, revealed, in part, to wash and air dry the nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) after use. When nebulizer equipment is dry, place it back in labeled plastic bag. Plastic bag will have the date that the equipment was opened on the outside of the bag Change aerosol unit, mouth piece, tubing and plastic bag on a weekly basis and label with date. Review of facility policy titled Oxygen Concentrators, with a revision date of January 26, 2017, revealed DO NOT keep distilled water in a resident's room. Always date an opened bottle. Review of Resident 14's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and Multiple Sclerosis (MS- a disease in which the immune system eats away at the protective covering of nerves). Observation of Resident 14's room on May 7, 2024, at 10:07 AM and May 8, 2024, at 10:26 AM, revealed that Resident 14's nebulizer equipment was lying on her bedside table, not in a bag. On May 8, 2024, at 10:42 AM, the surveyor showed Employee 3 (Registered Nurse) Resident 14's nebulizer equipment, which was not in a bag. At this time, Employee 3 stated it should be in a bag and she would take care of it. In a follow up interview with Employee 3 on May 8, 2024, at 11:04 AM, Employee 3 stated she placed Resident 14's nebulizer equipment in a bag. During an interview with the Nursing Home Administrator (NHA) on May 8, 2024, at 1:48 PM, he stated that Resident 14's nebulizer equipment should have been in a bag. Review of Resident 31's clinical record documented diagnoses that included chronic respiratory failure (lungs don't function as they should), 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), dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and chronic pulmonary edema (excess flid in the lungs). Review of Resident 31's physician orders included Ipratropium-Albuterol Solution (a medication use to prevent wheezing, and difficulty breathing) 3 milliliters inhale orally every 4 hours as needed for wheezing, start date December 13, 2022. Review of Resident 31's Medication Administration Record (MAR - documentation of medication administration)documented the last time Albuterol was administered to Resident 31 was January 23, 2024, at 395915 Page 13 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0695 7:26 AM. Level of Harm - Minimal harm or potential for actual harm Observations on May 6th at 12:14 PM; May 7th at 1:18PM; and May 8, 2024, at 10:11 AM Resident 31's nebulizer mask and treatment canister attached to mask were on the night stand not covered, tubing was dated January 23, 2024. It was also observed the top of night stand contained a white powdery residue that is able to be wiped off. Residents Affected - Some During an interview with Employee 3, Registered Nurse on May 8, 2024, at 10:39AM revealed the mask/treatment canister should be covered, or removed from Resident 31's room as she hasn't needed the medication and it should be discontinued. It was also revealed that the top of the nightstand needed to be cleaned and housekeeping would be notified. During an interview with the NHA on May 8, 2024, at 2:00 PM it was revealed that the mask should have been bagged and the night stand should've been cleaned. Review of Resident 32's clinical record revealed diagnosis that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypoxemia (low levels of oxygen in the blood). Observation of Resident 32 on May 6, 2024, at 11:35 AM and May 7, 2024, at 1:19 PM, revealed that Resident 32 was using oxygen running at 2 liters. Further interview with Resident 32 on May 7, 2024, at 1:19 PM, revealed that she uses oxygen daily. Review of Resident 32's clinical record revealed a nurse's progress note on February 26, 2024, at 9:39 PM, that included the following text: Resident continues on oxygen as previous with no shortness of breath noted, and another one on February 28, 2024, at 9:44 AM, that included the following text: Resident continues on oxygen. Review of Resident 32's current physician orders on May 7, 2024, revealed there was no order for oxygen. Further review revealed an order to change oxygen equipment tubing/nasal cannula/mask-humidifier bottle and clean filter weekly when in use, every night shift every Tuesday, with a start date of January 23, 2024. Review of Resident 32's current physician orders on May 9, 2024, revealed the following order: oxygen supplemental via nasal canal, with a start date of May 8, 2024. Review of Resident 32's February 2024 Treatment Administration Record (TAR) revealed a 5 was marked on February 27, 2024, indicating to see nurses' notes, for the resident's oxygen equipment tubing/nasal cannula/mask/humidifier bottle to be changed and filter to be cleaned. Further review of Resident 32's nurses' progress notes revealed there was not one written pertaining to the treatment order being completed. Review of Resident 32's March 2024 TAR revealed a blank space on March 19, 2024, for the resident's oxygen equipment tubing/nasal cannula/mask/humidifier bottle to be changed and filter to be cleaned, indicating it has not been completed. Review of Resident 32's comprehensive person-centered care plan on May 7, 2024, revealed a focus area that the resident has a chronic respiratory failure, obstructive sleep apnea, hypoxemia, and severe morbid obesity with alveolar hypoventilation, with an initiation date of July 11, 2023, but did 395915 Page 14 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0695 not mention the resident's oxygen use as an intervention. Level of Harm - Minimal harm or potential for actual harm Review of Resident 32's comprehensive person-centered care plan on May 9, 2024, under the same focus area listed above, revealed a new intervention that included: oxygen via nasal canal/mask as ordered by the medical director, with an initiation date of May 8, 2024. Residents Affected - Some During an interview with the Director of Nursing and Nursing Home Administrator on May 9, 2024, at 10:13 AM, they confirmed that they would have expected Resident 32's oxygen use to have been added to the care plan prior to May 8, 2024, along with an order to have been created for their oxygen use, as well as their oxygen equipment treatment to have been completed as ordered. Review of Resident 111's clinical record revealed diagnoses that included COPD and obstructive sleep apnea (intermittent airflow blockage during sleep). Observation of Resident 111's room on May 6, 2024, at 10:21 AM; May 7, 2024, at 9:02 AM; and May 8, 2024, at 8:57 AM, revealed Resident 111 receiving oxygen via an oxygen concentrator. Further observations during those times revealed a clear, gallon container of distilled water, sitting on Resident 111's windowsill. Observations revealed the water to be about 25% empty and the container was undated. On May 8, 2024, at 10:43 AM, Employee 3 was made aware of the undated distilled water in Resident 111's room. She stated that distilled water containers should be dated. In a follow up interview with Employee 3 on May 8, 2024, at 11:02 AM, she confirmed that the distilled water in Resident 111's room was open and undated and stated that she discarded it. During an interview with the NHA on May 8, 2024, at 1:52 PM, he stated that the opened distilled water should have been dated. 28 Pa. Code 211.12(d)(1)(2)(5) Nursing Services. 395915 Page 15 of 20 395915 05/09/2024 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 routine drugs to its residents and ensure procedures to assure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 17 residents reviewed (Resident 111). Findings Include: Review of Resident 111's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and obstructive sleep apnea (intermittent airflow blockage during sleep). During an interview with Resident 111 on May 6, 2024, at 10:20 AM, she stated that she wants her nicotine patch but is still waiting for it. She said she was told that the facility has not yet received it. Review of Resident 111's clinical record revealed an order for a Nicotine patch, with a start date of May 1, 2024, apply one patch once a day for smoking cessation. Review of Resident 111's medication administration record (MAR), dated May 2024, revealed that on May 1, 2, 3, 4 and 5, the Nicotine patch is signed off with a 9, meaning other/see nurse's note. On May 6, 2024, the Nicotine patch is signed off with a 5, meaning medication not administered/see nurse notes. Review of the corresponding nursing notes revealed the following regarding the Nicotine Patch: May 1- No corresponding note May 2- Medication unavailable May 3- Medication unavailable-on order from pharmacy May 4- Medication on order May 5- Medication on order May 6- Pending delivery from pharmacy. Medication administration observation on May 7, 2024, at 9:02 AM revealed Employee 4 (Licensed Practical Nurse) applying Resident 111's nicotine patch. During an interview with the Director of Nursing on May 9, 2024, at 9:29 AM, he stated that nicotine patches are on the list of medications that the pharmacy won't send unless there is an over the counter (OTC) authorization form completed. He stated that nicotine patches are not a house stock medication and there was a delay in nursing staff completing the OTC authorization form, resulting in a delay with pharmacy sending the medication. 395915 Page 16 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0755 28 Pa. Code 201.14(a) Responsibility of licensee Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.9(a)(1) Pharmacy services Residents Affected - Few 28 Pa. Code 211.12 (d)(2)(3)(5) Nursing services 395915 Page 17 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed on the South unit. Residents Affected - Few Findings include: Review of facility policy Hazard Analysis Critical Control Points and Food Safety, dated 2021, read, in part, staff will recognize potentially hazardous foods such as milk, and milk products, poultry, shell eggs, and meat and handle them carefully. The Director of Food Service and Registered Dietitian should determine the appropriate temperature ranges for the food service operation. The United States Department of Health and Human Services Food Code uses 41 degrees Fahrenheit for cold foods and 135 degrees for hot foods. Review of resident council meeting minutes for February 8, 2024, and March27, 2024, documented resident concern with cold food. Resident interviews during the initial pool process revealed concerns with the temperature of the food and beverages during meal service. Test tray completed on May 6, 2024, on south unit included maple glazed fish, egg noodles, carrots, cake, coffee, and milk. The coffee and milk temperatures were unsatisfactory; 134 degrees Fahrenheit, and 51 degrees Fahrenheit. During an interview with Employee 6, Dietary Aide, on May 6, 2024, at 1:30 PM it was revealed that the coffee should be 140 degrees Fahrenheit, and the milk should be 40 degrees Fahrenheit. During an interview with Employee 5, Food Service Director, on May 6, 2024, at 1:40 PM it was revealed that there isn't a test tray form or policy for food temperatures at point of service. During an interview with the Nursing Home Administrator on May 8, 2024, at 1:30 PM concerns regarding beverage temperatures during meal service on May 6th were noted and it was revealed that May 6th was the first day the main dining room was closed for renovations and all residents were served on meal trays. 28 Pa code 211.6 - Dietary Services 395915 Page 18 of 20 395915 05/09/2024 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, and interview it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area and one of one nourishment pantry. Findings include: Review of facility policy Food Storage, dated 2021, read, in part, all stock must be rotated with each new order received, old stock will be utilized first. Food should be dated as it is placed on the shelves. All storage containers or storage [NAME] must be accurately labeled and dated. Leftover food must be used within seven days or discarded as per the 2017 Federal Food Code. Observation in the dry store room on May 6, 2024, at 9:25 AM one half package of pasta was open and not securely closed. During an interview with Employee 5, Food Service Director, on May 6, 2024, at 9:25 AM it was revealed that the past should've been securely closed. Observation in the walk-in refrigerator on May 6, 2024, at 9:30 AM one container of thirty hard boiled eggs was not securely closed or date marked, one 25 pound container hard boiled eggs was open and not date marked when opened. During an interview with Employee 5, on May 6, 2024, at 9:30 AM it was revealed that the eggs should've been securely closed, and date marked. Observation in the walk-in freezer on May 6, 2024, at 9:42 AM one plastic bag with six beef hamburgers, one-five pound bag chicken breasts, and one-five pound bag of pork sausage were not date marked. During an interview with Employee 5, on May 6, 2024, at 9:42 AM it was revealed that the aforementioned bags of meat should've been date marked. Observation in the nourishment pantry freezer on May 6, 2024, at 9:53 AM two 1.5 quart containers of vanilla ice cream and 2 boxes of chocolate coated vanilla ice cream cones weren't labeled with a resident identifier and weren't date marked. Observation in the nourishment pantry refrigerator on May 6, 2024, at 9:56 AM one-32 ounce vanilla fortified nutritional shake, two-32ounce butter pecan fortified nutritional shakes were open with contents removed and not date marked with an open date, and one plastic thermal bowl of tomato soup was not date marked. During an interview with Employee 5, on May 6, 2024, at 9:56 AM it was revealed that the ice cream in the freezer doesn't belong to the facility and should be marked with a resident identifier and date marked, the fortified shakes should be date marked when opened, and the soup shouldn't have been stored in the refrigerator it should've been discarded after meal service. 395915 Page 19 of 20 395915 05/09/2024 Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview with the Nursing Home Administrator on May 8, 2024, at 1:30 PM concerns regarding food storage of the aforementioned items were noted, and no further information was provided. 28 Pa code 211.6 - Dietary Services Residents Affected - Some 395915 Page 20 of 20