Health inspection·March 31, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment in common areas and one of three resident rooms observed (South and East Hallways, Nurses Station, and Resident 1's room). Findings include: Review of facility policy, titled Cleaning & Disinfecting Environmental Surfaces last revised October 1, 2017, read, in part, Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. Observation in the South Hallway on March 31, 2025, at 10:41 AM, revealed three ceiling tiles with ring circle stains on them. Observation at the Nurse's Station on March 31, 2025, at 10:44 AM, revealed a large ceiling tile to the left of the station with a large brown ring circle stain. Observation in the East Hallway on March 31, 2025, at 10:46 AM, revealed one ceiling tile with a large brown ring circle stain on it, and a brown liquid stain that was dripping down the side of the wall. Further observation down the hallway revealed three ceiling tiles with ring circle stains on them. During an interview with Employee 1 (Maintenance Director) on March 31, 2025, at 11:12 AM, he revealed maintenance staff conduct environmental rounds and room checks throughout the facility on a regular basis to identify issues that require repair or replacement. He further revealed the facility has issues with the roof leaking during periods of heavy rain, and that staff should have identified the soiled ceiling tiles and replaced them, and the soiled wall should have been cleaned. Observation in Resident 1's room on March 31, 2025, at 11:23 AM, revealed one ceiling tile at the entrance to the room with a brown ring circle stain, and two large ceiling tiles in the middle of the room stained with brown liquid. During an interview with the Nursing Home Administrator on March 31, 2025, at 12:42 PM, he revealed he would expect the ceiling tiles to be identified as soiled and replaced, and environmental surfaces to be cleaned when soiled. 28 Pa. Code 201.18(e)(2.1) Management Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395915 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395915 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/31/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Transitions Healthcare Allens Cove 25 Cove Road Duncannon, PA 17020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)