Transitions Healthcare Autumn Grove Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to maintain a clean, safe, homelike environment for one of 57 rooms observed and for two of 57 bathrooms observed. Findings include: Facility policy dated 3/23/26, entitled Reporting Safety Hazards revealed the objective is to keep resident's environment as free of accidents and safety hazards as possible and that safety walkthrough will be done of each resident unit monthly. Observation of room [ROOM NUMBER] on 7/6/26, at 12:05 p.m. revealed four pieces of joined flooring tile with missing pieces measuring approximately 6 inches x 12 inches exposing the wood underneath the pieces of tile. There were also numerous cracked tiles throughout the room with some pieces missing from the corners of the tile. Interview with Resident R16 revealed that the floor has been bad for some time and although he/she has reported it, no one has addressed it. Resident R16 also reported concerns with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to consistently provide timely and necessary foot care for one of 19 residents reviewed (Resident R1). Findings include: Resident R1 was admitted to the facility on [DATE], with diagnoses that included Cellulitis (a skin infection caused by bacteria, most commonly affecting the lower leg. Symptoms include swelling, pain, warmth, and redness), Chronic Obstructive Pulmonary Disease (COPD - a condition that prevents airflow to the lungs resulting in difficulty breathing), and Gastroesophageal reflux disease (GERD - happens when stomach acid flows back up into the esophagus and causes heartburn). Resident R1's physician's orders revealed an order dated 5/8/26, for Podiatry (branch of medical care focused on assessment, diagnosis, and treatment of conditions affecting the feet, ankles and lower extremities) Consult and Treat as needed and a consent for 360 Care - podiatry signed and dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to serve food in a safe and sanitary manner during tray line and ensure that food was stored in accordance with standards for food safety, and failed to label food brought into the facility with the resident's name and use by date, and failed to maintain sanitary conditions in one of two pantry refrigerators (CD Unit). Findings include: A facility policy entitled Bare Hand Contact with Food and Use of Plastic Gloves dated 4/21/2025, indicated Single-use gloves will be worn when handling food directly with hands to assure that bacteria is not transferred from the food handlers' hands to the food product being served. The policy further stated that anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. Examples include after handling boxes, crates, or packages; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and any time a contaminated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain an effective pest control program to ensure a pest free environment in one of two pantries (CD Unit). Findings include: A facility policy entitled Pest Control dated 4/21/2025, indicated Routine pest control procedures will be in place. Observation of the pantry on CD Unit on 7/22/25, at 2:27 p.m. revealed numerous small flying insects on the walls, around the sink, around the garbage can and around the base of the floor where a portion of the baseboard was coming off. During an interview on 7/22/25, at 2:33 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed the presence of small flying insects in the CD pantry. LPN Employee E1 stated they are always bad in here and if someone leaves any food on the counters, it is much worse. The facility was unable to provide any evidence of prior pest control treatment to CD pantry. 28 Pa Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(3)(e)(2.1) Management

Based on review of clinical records and facility policy, and staff interview, it was determined that the facility failed to provide a clinical rationale for the continued use of a PRN (as needed) psychotropic (affecting the mind) medication beyond 14-days one of five residents reviewed (Resident R5).A facility policy entitled Behavior Health Program dated 4/21/25, indicated that the physician will limit the timeframe for PRN psychotropic mediations to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or prescribing practitioner. Residents R5's clinical record revealed an admission date of 1/13/24, with diagnoses that included bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs, called mania, and lows, known as depression) liver failure, difficulty eating, gall stones, and heart disease. The clinical record revealed a new physician's order dated 6/22/25, to administer Lorazepam (antianxiety medication) every six hours as needed for 45 days. Further review of Resident R5's clinical record lacked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to store food and food containers in a safe and sanitary manner in two of two nourishment refrigerators (A/B Unit, C/D/Unit). Findings include: A facility policy entitled, Food Safety for your Loved One dated 8/07/24, indicated food or beverages should be labeled and dated to monitor for food safety: food and beverages that have passed the manufacturer's expiration date will be discarded; food or beverage items without an manufacturer's expiration date should be dated upon arrival in the facility and thrown away seven days after the date marked; and foods in unmarked or unlabeled containers should be marked with the current date the food item was stored and the resident's name. A facility policy entitled, Food Brought in from Outside Sources and Personal Food Storage dated 8/07/24, indicated that foods and beverages brought in from outside sources that require refrigeration or freezing should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed provide an environment that enhances resident's quality of life for three of 21 residents reviewed (Residents R25, R65, R69). Findings include: Resident R25's clinical record revealed an admission date of 6/14/24, with diagnoses that included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), dementia, tremors, need for assistance with personal care, and cognitive communication deficit (communication difficulty that is caused by a cognitive deficit rather than a language or speech deficit). The clinical record lacked evidence of a physician's order and/or plan of care to address him/her consuming meals while sitting in the hall at the nurse's station. Resident R25's most recent Admission/5-Day Minimum Data Set (MDS-standardized assessment tool used to evaluate the health and functional abilities of residents in Medicare or Medicaid certified nursing homes) Section C0500 with an Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interview, it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of two of 21 residents reviewed (Residents R15 and R32). Findings include: MDS instructions for section N0350A Medications - Insulin Injections revealed to Record the number of days that insulin injections were received during the last 7 days or since admission / entry or reentry if less than 7 days. Resident R15's clinical record revealed an admission date of 4/11/24, with diagnoses that included Type II diabetes (condition that affects how your body uses insulin), breast cancer, and dementia (loss of cognitive functioning affecting a persons memory and behaviors). Resident R15's clinical record revealed a physician's order dated 4/12/24, for Liraglutide injection (an antihyperglycemic [medication to reduce elevated blood sugar levels] injection used to help control blood sugar, which is not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to maintain proper care of respiratory equipment for one of two residents reviewed for respiratory services (Resident R66). Findings include: Review of facility policy dated 8/7/24, entitled Oxygen Concentrators indicated The facility will include cleaning of humidifiers and filters to maintain optimal function and infection control procedures and for filters clean weekly and as needed, rinse thoroughly with clear water, and towel day to remove excess water. Resident R66's clinical record revealed an admission date of 2/17/20, with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that results in difficulty breathing, cough, and mucus production), dementia (loss of cognitive functioning affecting a persons memory and behaviors), and high blood pressure. Resident R66's physician's order dated 2/27/24, revealed that oxygen was ordered at three liters per minute every shift via nasal cannula (tubing that enters into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility dialysis (a blood purifying treatment given when your kidneys are not functioning) center contract, facility policy, and clinical record, and staff interview, it was determined that the facility failed to maintain records relating to dialysis communication for one of one residents reviewed for dialysis (Resident R79). Findings include: Review of dialysis contract between the facility and the dialysis clinic dated 7/18/14, revealed that the responsibility of the skilled nursing facility included that the healthcare staff will make an assessment of each patient's physical condition and determine whether the patient is stable enough to be dialyzed on an outpatient basis. If it is determined that a patient is sufficiently stable, this assessment will be communicated to the facility's nurse manager or his or her designee. This assessment and communication will occur prior to each and every transfer of a patient to the dialysis clinic for hemodialysis on an outpatient basis regardless of the number of times any particular patient may be transferred and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies, facility documentation and staff interviews, it was determined that the facility failed to ensure facility staff were properly trained to provide basic life support including, Heimlich Maneuver (emergency life-saving procedure that is done immediately when a person is choking which can increase the chances of survival after choking) and cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) for 85 of 135 facility personnel. Findings include: Review of facility policy entitled Cardiopulmonary Resuscitation dated [DATE], revealed facility personnel will be trained on the imitation of cardiopulmonary resuscitation and basic life support. Review of facility policy entitled Foreign Body Airway Obstruction Management dated [DATE], revealed facility personnel will be trained on the procedure for foreign body airway…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of job descriptions, facility cardiopulmonary resuscitation (CPR-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest) records, facility assessment, and staff interviews, it was determined that the facility failed to ensure that licensed nursing staff have the specific competencies and skill sets necessary to care for resident's needs. Findings include: Review of facility Job Description entitled Licensed Practical Nurse dated 3/2017, revealed that CPR and AED (Automated External Defibrillator-medical device used to help those experiencing sudden cardiac arrest) certification are minimum requirements to perform the job. The review also revealed an essential job function is to attend in-services and/or educational programs in accordance with company and regulatory requirements. Review of Job Description entitled Certified Nursing Assistant dated 3/2017, revealed an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility records and job descriptions, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to make certain that professional licensed staff implemented life-saving interventions in response to a choking episode that led to death and failed to ensure the provision of food in a form to meet individual resident needs. Findings include: Review of the job description for the NHA revealed that the NHA's purpose is to lead and direct the overall operations of the nursing home facility in accordance with customer needs, government regulations, and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business operations. The NHA's essential job functions include being responsible to ensure quality and proper resident care and services and possess and display a practical knowledge of nursing facility operations. Review of the job description for the DON revealed that the DON's purpose is to manage the overall operations of the Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.