Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Transitions Healthcare North Huntingdon during CMS and state inspections, most recent first.
Expired medical supplies and items were found in the A/B Nursing Unit medication room, including Foley catheters, IV needles, CultureSwab kits, a COVID-19 antigen self-test, sterile NS, and other supplies. The facility policy required outdated items to be removed from stock and disposed of, and the NHA confirmed the items were not properly stored and/or disposed of.
A facility failed to keep care plans updated and person-centered for three residents. One resident with PTSD, depression, and behavioral concerns had a care plan that did not identify specific triggers, while another resident with TBI, aphasia, and seizure disorder had no care plan for g-tube feedings despite current orders. A third resident with neurogenic bladder and spina bifida had no care plan for an indwelling Foley catheter even though current orders required Foley care and flushing; the DON and NHA acknowledged the gaps during interview.
Respiratory care was not provided as ordered for two residents. One resident with CAD, HF, and HTN had BiPAP and oxygen orders, but the oxygen tubing on the concentrator was dated weeks earlier and the chart lacked maintenance orders until after facility notification. Another resident with respiratory failure and COPD had an oxygen order, but the tubing was not labeled or dated and the resident said it had not been changed. The DON and NHA confirmed the issue.
A resident with ESRD, HTN, and DM had ordered dialysis three times weekly, but the dialysis communication binder and treatment forms were repeatedly left incomplete. The dialysis center nurse did not consistently document pre- or post-treatment VS and weight, and the dialysis nurse often did not sign the forms, which the NHA and DON confirmed.
An LPN failed to follow hand hygiene and safe medication-handling practices during med pass for multiple residents. One tablet was dropped on the med cart, picked up with bare hands, and administered, while another LPN touched stock tablets and popped multiple blister-pack meds into his hands before placing them in cups and crushing them for administration. The DON confirmed staff were not to touch residents’ medications with bare hands.
The facility failed to follow its call bell policy requiring immediate response to resident requests, resulting in multiple cognitively intact or moderately impaired residents who needed assistance with toileting and transfers waiting extended periods after activating call lights. Several residents with conditions such as diabetes, COPD, heart failure, traumatic brain injury, and end-stage renal disease reported routinely waiting 30 minutes or longer, sometimes over an hour, for help with toileting or incontinence care, with one resident documenting hours-long waits in a grievance and another reporting having called 911 when staff did not respond. Resident council minutes on two occasions recorded concerns that call bells were not answered timely, and facility leadership acknowledged that call lights were not consistently accessible or answered promptly, in violation of applicable Pennsylvania resident care, nursing services, and resident rights regulations.
The facility failed to maintain resident dignity and honor resident rights related to toileting and incontinence care. A resident with cognitive impairment and mobility needs was required to use a bedpan for bowel movements despite an active physician order and her stated preference for a bedside commode, which had been removed from her room and not returned. Another resident, fully dependent for toileting, reported going nearly an entire day without a brief change despite multiple calls for assistance and involvement of his daughter. A third resident, requiring substantial assistance, reported being left on a bedpan for an extended period while she slept. Leadership acknowledged that the facility did not ensure care was provided in a manner that maintained resident dignity.
The facility failed to follow physician-ordered blood pressure (BP) parameters and its own medication administration policy for two residents receiving antihypertensive medications. One resident with COPD and hypertension received metoprolol on multiple occasions despite documented systolic BP readings below the ordered hold parameter. Another resident with diabetes and hypertension had an order for lisinopril with a specified systolic BP hold parameter, but there was no documented BP monitoring for an extended period to support safe administration. The NHA and DON acknowledged that these issues resulted in significant medication errors for two of five residents reviewed.
A resident with chronic kidney disease and heart failure, previously without documented tremors or seizure-like activity, developed new Parkinson’s-like tremors, flopping and jerking movements, yelling out in pain, back arching suggestive of seizure activity, and decreased oxygen saturation along with an abnormal temperature. Nursing notes showed that provider and responsible party notification fields were marked as not applicable, and the clinical record lacked evidence that the medical provider was notified of these significant changes before the resident was sent to the hospital and later admitted to the ICU. This failure occurred despite a facility policy requiring notification of residents, providers, and representatives when a change in condition occurs.
A medication cart was left unattended in a hallway with an open laptop displaying resident-identifiable information, allowing any passerby to view confidential medical data. Staff and leadership confirmed the incident, which was not in accordance with facility policy on safeguarding PHI.
Multiple residents reported prolonged call light response times, with some waiting up to an hour and a half for assistance. Several residents described staff turning off call lights without providing help, feeling rushed during care, and not receiving timely assistance, particularly during night shifts. Facility leadership confirmed insufficient staffing to meet resident needs, and documentation showed ongoing concerns about delayed responses and unmet care needs.
A resident with severe cognitive impairment and multiple medical conditions experienced several changes to prescribed medications, including Ativan and Haldol, without the facility notifying the resident's representative in advance or discussing the risks, benefits, or alternatives. Review of records and staff interviews confirmed that required communication and documentation did not occur, in violation of resident rights and care policies.
A resident with heart disease, dementia, and asthma had a physician's order for continuous oxygen via nasal cannula, but the MAR lacked documentation of oxygen administration on several dates. The facility did not ensure complete and accurate clinical records for this resident.
The facility failed to properly design, approve, and follow its Winter five-week cycle menu, leading to potential inaccuracies in portion sizes and food consistencies for therapeutic diets. Documents lacked RD approval, and menu modifications were not pre-planned or reviewed, creating potential for inappropriate servings.
Transitions Healthcare North Huntingdon was found non-compliant with maintaining a homelike environment. Observations revealed peeling paint, gashes in walls, and splintering wood in resident rooms, hallways, and the dining room. The Nursing Home Administrator and Maintenance Director confirmed these deficiencies.
The facility failed to ensure privacy for resident group meetings, as staff repeatedly interrupted a meeting in the dining room despite posted signage. The Nursing Home Administrator confirmed that staff could use an alternative route, acknowledging the failure to provide a private space for the group.
The facility failed to provide four residents with the opportunity to formulate advance directives, as required by their policy. Despite having significant health conditions, these residents' clinical records lacked documentation of being informed about or given the chance to create an advance directive, confirmed by a social worker.
The facility failed to complete MDS assessments within the required time frame for several residents. The RAI User's Manual mandates that admission MDS assessments be completed within 14 days and annual assessments by the ARD. However, assessments for some residents were overdue, as confirmed by the RNAC and Nursing Home Administrator. The issue arose after the previous RNAC left without notice, resulting in multiple overdue assessments.
The facility failed to properly store and dispose of medications and supplies in the Orchards medication room. Expired items, including vacutainers, IV start kits, swabsticks, scalpels, glucometer testing solutions, and an undated vial of insulin, were found. The DON and Nursing Home Administrator confirmed these deficiencies.
The facility failed to maintain call light equipment, affecting five of seven residents. Observations showed that room lights were illuminated, but the nurses' station monitoring panel did not reflect this. Nurse Aides confirmed the panel's unreliability, and the Director of Nursing acknowledged the issue.
A resident with diabetes and coronary artery disease, assessed as at risk for elopement, exited the facility through an alarmed door that was reset by staff who assumed the alarm was triggered by an ambulance crew. The resident was later found near a gas station, expressing a desire not to return and making threats of self-harm, leading to a hospital transport for mental health evaluation.
Expired Medical Supplies Found in Medication Room
Penalty
Summary
The facility failed to ensure that medical supplies and medications in one of two medication rooms, the A/B Nursing Unit Medication Room, were properly stored and/or disposed of. The facility policy titled "Storage of Medications" dated 4/1/26 stated that outdated, contaminated, or deteriorated items would be removed from stock and disposed of accordingly. During an observation of the A/B nursing unit medication room on 4/28/26 at approximately 12:32 p.m., surveyors found multiple expired items in stock, including Foley catheters, needleless connectors, a COVID-19 antigen self-test, CultureSwab collection and transport systems, IV needles, IV start kits, extension sets, sterile normal saline, a medical drainage bag, and an Amsino Amsure Foley insertion tray. During an interview on 4/28/26 at approximately 2:30 p.m., the Nursing Home Administrator confirmed that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in one of two medication rooms.
Incomplete and Non-Individualized Care Plans
Penalty
Summary
The facility failed to ensure that three residents had updated, person-centered care plans individualized to their specific needs. Review of the facility policy indicated each resident should have a comprehensive care plan developed within 7 days of the comprehensive assessment and that it should be individualized, measurable, and reflect the resident’s medical, nursing, mental, psychological, cultural, and personal needs. Clinical record review showed Resident R12 had diagnoses including stroke, HTN, cirrhosis, diabetes, and PTSD, and the care plan dated 4/10/26 addressed altered mood and behaviors related to depression, PTSD, anxiety, verbal behaviors, inappropriate comments toward women, and racial slurs, but did not document what triggered the PTSD-related behaviors; the plan only stated the resident was to be assessed and monitored for triggers of mood/behaviors, loss of independence, and feelings of helplessness. Clinical record review also showed Resident R23 had diagnoses including traumatic brain dysfunction, aphasia, and seizure disorder, with physician orders for enteral feeding every four hours, tube checks, stoma care, syringe and tubing changes, head-of-bed elevation during feedings and medication administration, and Isosource 1.5 bolus feedings three times daily; however, the care plan dated 4/9/26 contained no plan of care for the g-tube or tube feedings. Resident R99 had diagnoses including HTN, neurogenic bladder, spina bifida, and hydrocephalus, with physician orders for Foley catheter flushing as needed for blockage, Foley care every shift, and an order for an indwelling Foley catheter with drainage bag; however, the care plan dated 4/28/26 contained no plan of care for the indwelling Foley catheter. During interview, the DON and NHA reviewed these care plans and acknowledged that R12’s triggers were not documented and that R23 and R99’s care plans should have reflected the current physician orders.
Respiratory Care and Oxygen Equipment Not Maintained
Penalty
Summary
Appropriate respiratory care was not provided for two residents, and oxygen equipment was not maintained as ordered. Facility policy required weekly cleaning and maintenance of oxygen concentrator components, including filters, humidifiers, tubing, and cannulas, and the CPAP/BIPAP policy required verification of the physician’s order and oxygen source, connection of tubing to the oxygen enrichment adapter and oxygen source, and weekly cleaning of the system. Resident R53 had diagnoses including CAD, heart failure, and hypertension, and had physician orders for BiPAP with 2 liters per minute of oxygen bleed-in and 5 liters per minute of oxygen, along with weekly oxygen tubing and set-up changes. On 4/27/26, the resident was observed with oxygen tubing connected to the oxygen concentrator that had a label dated 4/6/26, and the clinical record showed there were no orders for oxygen concentrator maintenance related to filters, humidifier bottle, or tubing until after facility notification. Resident R133 had diagnoses including respiratory failure, COPD, and anxiety disorder, and had an order for 2 liters per minute of oxygen with weekly changes and cleaning of oxygen equipment. On 4/27/26, the resident was observed with oxygen tubing connected to the oxygen concentrator, but the tubing had not been labeled or dated, and the resident stated the tubing had not been changed.
Incomplete Dialysis Communication
Penalty
Summary
Facility failed to maintain consistent dialysis communication for Resident R56, who was admitted to the facility with diagnoses of hypertension, diabetes, and end stage renal disease. The resident had a physician order for dialysis three times weekly at a dialysis center with a scheduled chair time of 10:30 a.m., and the care plan also directed dialysis treatments as scheduled on Monday, Wednesday, and Friday. Review of the resident’s dialysis communication forms from 3/27/26 through 4/27/26 showed multiple incomplete entries. On several dates, the dialysis center nurse did not complete vital signs or weight before or after treatment and the dialysis nurse did not sign the forms. On other dates, the dialysis center nurse did not complete post-treatment vital signs or weight and the dialysis nurse did not sign the forms, and on additional dates the dialysis nurse did not sign the communication forms. During interview, the Nursing Home Administrator and Director of Nursing confirmed the facility failed to make certain consistent dialysis communication was maintained.
Improper Hand Hygiene and Medication Handling During Administration
Penalty
Summary
The facility failed to ensure proper infection control practices were followed during medication administration for three residents. The facility policy required hand hygiene before preparing or handling medications and the use of a barrier to carry medication containers into a resident’s room. During observation of medication administration, an LPN prepared Lopressor for one resident, touched the medication while splitting it, dropped it onto the medication cart, picked it up with bare hands, and then placed it into the medication cup before administering it. The LPN later confirmed the tablet should not have been touched and a new tablet should have been obtained after it dropped onto the cart. During additional observations, another LPN prepared medications for two residents and touched stock tablets with bare hands before placing them into medication cups. The LPN also popped multiple blister-pack medications directly into his hands before placing them into a cup, then handled the medications again to place them into a pouch for crushing and emptied the crushed medications into pudding for administration. For another resident, the same LPN touched tablets with bare hands and popped several blister-pack medications into his hands before placing them into the medication cup. The LPN confirmed he should not pop or pour medications into his hands and stated that if he did, he should wear gloves. The DON also confirmed staff were not to touch residents’ medications with bare hands.
Failure to Ensure Timely Response to Call Lights for Residents Requiring Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure call lights were accessible and answered in a timely manner for multiple residents who required staff assistance, particularly with toileting and transfers. Facility policy on call bells dated 4/1/25 required staff to respond to resident requests and needs when using the call bell system and, when answering from the nurse’s station, to ensure staff respond to resident requests immediately. Despite this policy, resident interviews, clinical record reviews, and resident council minutes documented repeated delays in call light responses and concerns about accessibility and timeliness. Resident R1, admitted 6/8/25 with diagnoses including adjustment disorder, diabetes mellitus, and hypertension and a BIMS score of 12, required supervision or touching assistance for toileting hygiene and substantial/maximal assistance for toilet transfers. R1 reported using the call light for help and stated it took a half hour or more, sometimes more than an hour, to receive assistance. Resident R2, admitted 7/22/24 with hypertensive chronic kidney disease, adjustment disorder, and hypertension and a BIMS of 15, required partial/moderate assistance with toileting hygiene and was unable to perform toilet transfers due to medical condition; R2 stated it took a half hour and sometimes much longer to get help after using the call light. Resident R3, with osteomyelitis of the vertebra, bipolar disorder, and hypertension and a BIMS of 15, required partial/moderate assistance with toileting hygiene and toilet transfers and reported that call light responses took at least thirty minutes, citing one instance of waiting from 11:45 a.m. to 1:15 p.m. Resident R4, admitted 5/4/21 with COPD, diabetes mellitus, and depression and a BIMS of 15, required partial/moderate assistance with toileting hygiene and supervision or touching assistance for toilet transfers and stated that after using the call light, there was always a wait, sometimes thirty minutes and other times much longer. Resident R5, admitted 4/3/25 with traumatic brain injury, end-stage renal disease, and diabetes mellitus and a BIMS of 15, was dependent for toileting hygiene and toilet transfers and had filed a grievance on 12/31/25 documenting hours of waiting for a brief change after calling for assistance. Resident R6, admitted 2/15/26 with hypertension, heart failure, COPD, and a BIMS of 11, required substantial/maximal assistance with toileting hygiene and toilet transfers and reported always having to wait for help and having called 911 on occasion when the wait was too long. Resident council minutes from two separate meetings documented that call bells were not being answered in a timely fashion, and in an interview, the Nursing Home Director and DON confirmed the facility failed to ensure call lights were accessible and answered promptly, in violation of 28 Pa. Code 211.10(c)(d), 211.12(d)(1)(2)(3)(5), and 201.29(i)(o).
Failure to Maintain Resident Dignity in Toileting and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a manner that maintained resident dignity and honored resident rights related to toileting and incontinence care. One resident with adjustment disorder, diabetes mellitus, hypertension, and a BIMS score of 12 reported that staff made her use a bedpan for bowel movements despite an active physician order for use of a bedside commode at the bedside with assistance of two for transfers. She stated that the bedside commode had been removed from her room and not returned, and that when she requested it, staff told her to use the bedpan instead. Review of her clinical record confirmed the ongoing physician order for bedside commode use, indicating that staff were not following the order and were not honoring her expressed preference for the commode. Another resident with traumatic brain injury, end stage renal disease, diabetes mellitus, and a BIMS score of 15, who was dependent for toileting hygiene and toilet transfers, filed a grievance stating that he went from 9:30 a.m. to 8:30 p.m. without having his brief changed. He reported calling for a nurse multiple times, speaking with a nurse aide around 4:30 p.m. who said she would return but did not, and that after his daughter called the facility in the evening, a nurse came but it then took an additional 30–40 minutes to find an aide to change him. A third resident with similar diagnoses and a BIMS score of 15, requiring substantial/maximal assistance for toileting hygiene, filed a grievance stating she was placed on a bedpan at 10:15 p.m., fell asleep, and awoke at 11:43 p.m. still on the bedpan, after which she called staff to have it removed. In an interview, the Nursing Home Director and Director of Nursing confirmed the facility failed to ensure care was provided in a manner that maintained resident dignity, in violation of resident rights requirements.
Failure to Follow BP Parameters for Antihypertensive Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors by not following physician orders and facility policy for safe medication administration and required monitoring. Facility policy dated 04/01/25 required that medications be administered in a safe and effective manner and that vital signs or other monitoring parameters ordered or deemed necessary be obtained and recorded prior to administration. For one resident with COPD and high blood pressure, a physician order dated 3/20/25 directed that 12.5 mg of metoprolol be given once daily and held if the systolic blood pressure was less than 100 mm Hg. Review of the January 2026 MAR showed that this medication was administered on multiple dates when the documented systolic blood pressures were below 100 mm Hg, including readings of 98/61, 98/61, 98/63, 87/56, and 97/54. For another resident with diabetes and high blood pressure, a physician order dated 12/27/25 directed that 5 mg of lisinopril be given once daily and held if the systolic blood pressure was less than 120 mm Hg. Review of this resident’s record failed to show any documentation of a blood pressure measurement after 12/29/25, despite the order requiring blood pressure monitoring to determine whether the medication should be administered or held. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that residents were free of significant medication errors for two of five residents reviewed.
Failure to Notify Provider of Significant Change in Resident Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the medical provider of a resident’s change in condition as required by facility policy. The facility’s “Change in Condition” policy dated 4/1/25 states that residents, medical providers, and resident representatives are to be informed of changes in the resident’s condition. The resident involved had diagnoses including chronic kidney disease and heart failure and was documented on the MDS as having no cognitive impairment. Review of the clinical record from admission through mid-November showed no prior documentation of tremors, convulsions, seizures, Parkinson’s disease, Parkinsonism, or yelling out. The resident’s care plan identified risk for complications related to high blood pressure, with interventions to observe for signs and symptoms of elevated blood pressure. On a mid-November date, nursing documentation indicated that information was passed from the night nurse that the resident was having Parkinson’s-like tremors with no prior history. The nurse and CNA repeatedly adjusted the resident in bed due to flopping and rapidly flapping legs, and the resident only briefly opened her eyes. The resident was yelling out in pain and received PRN pain medication but could not verbalize the pain location. While in a wheelchair, she arched her back as if having a seizure and snored loudly, taking only a few bites of food before snoring again. A skilled nursing note from that day documented yelling out in pain and marked provider and responsible party notification fields as “not applicable.” Later that day, the resident was transported to the hospital for severe back pain, with documentation of eyes closed, posturing of head, hands, and arms, and leg spasms and jerking, and inability to feed herself due to rigid hands. Vital signs showed oxygen saturation at 92% and 91% on room air, lower than any prior readings since admission, and a temperature flagged as abnormal by the electronic charting system. The clinical record did not show that the medical provider was notified of these changes when they occurred. The Nursing Home Administrator and DON confirmed that the facility failed to notify the medical provider of the change in condition for this resident.
Failure to Maintain Confidentiality of Resident Medical Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information when a medication cart on the orchards unit was left unattended in the hallway with an open laptop displaying resident-identifiable information. This allowed any passerby to view personal and confidential resident data. The facility's policy on safeguarding posted protected health information (PHI) requires that resident PHI be protected from intentional or unintentional view in public areas. During observation, staff confirmed that the medication cart was left unattended with the laptop open, and both the LPN responsible and facility leadership acknowledged the incident.
Failure to Provide Sufficient Nursing Staff and Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of nine out of thirteen residents, as evidenced by multiple resident interviews, observations, and review of facility documents. Several residents reported long call light response times, with some waiting up to an hour and a half for assistance. Specific instances were documented, including a resident who kept a notepad of delayed response times, ranging from 20 to 55 minutes. Residents also described situations where staff would turn off call lights without providing the requested assistance, and some reported feeling rushed during personal care, such as bathing, or not receiving help at all, especially during night shifts staffed by agency personnel. One resident was observed to have facial hair, suggesting a lack of attention to personal grooming needs. Resident Council minutes from two separate meetings indicated ongoing concerns about long call light response times, and a grievance documented a resident not being changed during the night shift, resulting in the resident and their bed being soaked. During interviews, both the Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to ensure sufficient staffing to meet resident needs. These findings were cited as violations of state regulations regarding the responsibility of the licensee and nursing services.
Failure to Notify Resident Representative of Medication Changes
Penalty
Summary
The facility failed to inform a resident's representative in advance about proposed care, specifically regarding changes in prescribed medications, including the risks and benefits associated with those medications. Review of the clinical record for a resident with severe cognitive impairment and multiple diagnoses, including traumatic subarachnoid hemorrhage, dysphagia, diabetes, and seizures, showed that there were several changes to the resident's medication orders, such as adjustments to Ativan and Haldol dosages. Despite facility policy requiring notification and documentation of such changes, there was no evidence that the resident's representative was notified or that discussions occurred regarding the advantages, disadvantages, or alternative options for the medication changes. Interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility did not inform the resident's representative as required. The deficiency was identified through review of nurse progress notes and psychiatry recommendations, which lacked documentation of any communication with the resident's representative about the medication changes. This failure was found to be noncompliant with state regulations regarding resident rights and care policies.
Incomplete Documentation of Oxygen Administration in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented. Specifically, a review of the clinical record for a resident with heart disease, dementia, and asthma revealed a physician's order for continuous oxygen administration via nasal cannula at 4 liters per minute every shift. However, the medication administration record (MAR) for May did not include documentation that the resident received oxygen as ordered on multiple specified dates. The Nursing Home Administrator confirmed these findings, indicating that the facility did not maintain complete and accurate clinical records for this resident.
Deficiency in Menu Planning and Approval
Penalty
Summary
The facility failed to properly design, approve, and follow its Winter five-week cycle menu and modifications, as evidenced by a review of facility policies, documents, observations, and staff interviews. The facility's 'Menu Planning' policy required that menus be completed at least two weeks in advance and approved by the registered dietitian (RD). However, the Winter cycle menu extension sheets did not provide guidance for regular and therapeutic diets as outlined in the facility's template, and they lacked portion sizes and food consistency guidance for Mechanical soft and Puree diets. This created the potential for dietary staff to serve inaccurate portion sizes and food consistencies. The facility's documents, such as the 'SLP Mech Soft Recommendations' and 'Puree Serving Guidelines,' lacked documented evidence of review and approval by the facility's RD. These documents provided conflicting recommendations for portion sizes, which could lead to inappropriate servings for residents on puree diets. Additionally, the 'Small, Regular and Large Portion Sizes' document also lacked RD approval. The Mechanical Soft/Puree menu extension sheets included items like rice pilaf and pineapple, which were not permitted for these diets according to the SLP's recommendations. Interviews with staff, including the Food Service Director (FSD) and a cook, confirmed the discrepancies in the menu extension sheets and the lack of RD approval. The facility also failed to pre-plan menu modifications, such as substituting chef salad for residents on a renal diet, without RD review and approval. These failures in menu planning and approval created the potential for conflicting guidance, which may result in residents receiving inappropriate and inaccurate portion sizes and food product consistency for their prescribed therapeutic diets.
Plan Of Correction
The RD reviewed the current menu cycle for the remainder of this season. Menus, extensions, and diet consistencies were updated and signed by the RD and reviewed with the CDM. Extension sheets include portion sizes for all diets and combined guidance for Mechanical soft and Puree diets consistencies. For subsequent seasons, the RD will review and sign the menu, extensions, and consistencies. RD provided education to the CDM on menus, extensions, and diet consistency. The CDM will provide education to the dietary line staff on how to follow the menu, recipe, extensions, and portion size for each meal respectively. The RD/designee will complete audits of three meals a week for four weeks to ensure that the meal is prepared and served per the menu and with appropriate portion control. Audits will be taken to QAPI for review and discussion.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
Transitions Healthcare North Huntingdon was found to be non-compliant with the requirements for maintaining a safe, clean, comfortable, and homelike environment as per 42 CFR Part 483, Subpart B. During an observation conducted on February 5, 2025, several deficiencies were noted throughout the facility. In resident rooms 123 W, 126 W, 119 W, and 203 D and W, there were issues such as peeling and scuffed paint, deep gashes in the walls, and peeling wallpaper. Additionally, the doors to the dietary department and the hallway wall underneath the dining room bulletin boards exhibited scuff marks, peeling paint, and broken plaster. Further observations revealed that the dining room had peeling paint on the walls, and the door jam leading to the outside courtyard had peeling plaster and lacked proper baseboard covering. The wooden handrails throughout the facility, particularly outside the dietary department and conference room, were found to have gashes with splintering wood and unfinished surfaces. These findings were confirmed during an interview with the Nursing Home Administrator and Maintenance Director, who acknowledged the facility's failure to maintain a homelike environment.
Plan Of Correction
Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law. Areas identified during the survey have been repaired by placing InPro wall protection behind the headboards, painting and plastering as indicated, and sanding and staining as indicated. Areas repaired are as follows: - Resident room 123 W (window) the area behind the resident's bed headboard contained peeling and scuffed paint. - Resident room 126 W the area behind the resident's bed headboard contained a deep gash in the wall along with peeling paint. - Resident room 119 W the area behind the resident's bed headboard contained peeling paint. - Resident room 203 D (door) and W the area behind the resident's bed headboard contained peeling wall paper. - The doors to the dietary department contained scuff marks and peeling paint. - The hallway wall underneath the dining room bulletin boards contained a deep gash in the wall with broken plaster. - The wall in the dining room contained peeling paint. - The door jam for the door leading from the dining room to the outside courtyard contained peeling plaster and failed to contain a proper baseboard covering. - The wooden handrails contained gashes that contained splintering wood and non-smooth unfinished surfaces, located in the following hallways: outside the dietary department and outside the conference room. A schedule has been implemented to resurface and paint the remaining handrails in the facility. Project will be completed by July 31, 2025. A schedule has been implemented to place InPro wall protection behind an additional 33 beds. Project will be completed by July 31, 2025. The Maintenance Director will complete a facility walk thru audit. Any other areas identified will be repaired. The Administrator/designee will complete staff training on utilizing the TELS electronic maintenance system when environmental concerns are identified so the work can be completed in a timely manner. Environmental audits will be conducted by the NHA or designee weekly x 2, then monthly thereafter prior to the safety committee meetings. The Administrator will complete weekly audits of the progress of handrail resurfacing project and InPro wall protection project to ensure completion as scheduled. The Administrator/designee will complete a comparison audit of work needing completed against work completed to maintain a clean, comfortable and home-like environment. Audit will be completed weekly for two weeks. Results will be taken to the QAPI committee for review of findings and further interventions if indicated.
Facility Fails to Provide Private Space for Resident Group Meetings
Penalty
Summary
The facility failed to provide a private space for the resident group meetings, as evidenced by multiple interruptions during a Resident Group meeting held in the facility dining room. Despite signage indicating that a private meeting was in progress, facility staff entered the room 13 times to use it as a passageway, disrupting the meeting. When questioned by the surveyor, a staff member acknowledged the signage but stated she needed to access the front office. Additionally, a staff member was observed standing close to the dining room door, potentially overhearing the meeting, and had to be instructed to move further away. The issue of interruptions was corroborated by the Ombudsman, who confirmed that previous resident group meetings and training sessions had also been disrupted. The Nursing Home Administrator admitted that the facility layout included a connecting hallway, which staff could use instead of the dining room, acknowledging the failure to provide a private space for the resident group. This deficiency affected all ten residents involved in the group meeting.
Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to provide the opportunity for residents to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated. This deficiency was identified for four out of five residents reviewed during the survey. The facility's policy, reviewed on multiple occasions, states that it is their intent to inform and provide residents with written information regarding their right to formulate advance directives. However, the clinical records for Residents R23, R65, R84, and R87 did not contain an advance directive or documentation indicating that these residents were given the opportunity to formulate one. Resident R23 was admitted with diagnoses including diabetes, depression, and high blood pressure, while Resident R65 had similar diagnoses. Resident R84 was admitted with pulmonary fibrosis, reduced mobility, and obesity, and Resident R87 was readmitted with scoliosis, difficulty speaking, and diabetes. Despite these varied and significant health conditions, there was no documentation in their clinical records to show that they were informed about or given the chance to create an advance directive. This was confirmed by Social Worker Employee E2 during an interview, who acknowledged the absence of such documentation in the clinical records of the mentioned residents.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required time frame for seven out of 20 residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 14 days following admission, and an annual MDS assessment must be completed by the Assessment Reference Date (ARD). However, the facility did not adhere to these guidelines, resulting in late MDS assessments for several residents. Specific residents had MDS assessments completed past their due dates, with some assessments being overdue by several days. The deficiency was confirmed during interviews with the Registered Nurse Assessment Coordinator (RNAC) and the Nursing Home Administrator. The RNAC acknowledged the late assessments, attributing the issue to the previous RNAC leaving without notice, which led to multiple overdue assessments. The Nursing Home Administrator also confirmed the facility's failure to complete the MDS assessments on time for the affected residents. This deficiency was noted under the regulation 28 Pa. Code: 211.5(f) concerning clinical records.
Improper Storage and Disposal of Medications and Supplies
Penalty
Summary
The facility failed to ensure that medications and medication supplies were properly stored and disposed of in the Orchards medication room. During an observation, several expired items were found, including 57 vacutainers, multiple intravenous (IV) start kits, Povidone-iodine swabsticks, disposable scalpels, a bottle of glucometer testing solutions, and an opened, undated vial of insulin. The Director of Nursing confirmed the expiration of these items during an interview. Additionally, the Nursing Home Administrator acknowledged the facility's failure to properly store and dispose of these medications and supplies.
Failure to Maintain Call Light Equipment
Penalty
Summary
The facility failed to maintain call light equipment for five of seven residents. During observations, it was noted that the lights above the room doors for several residents were illuminated, but the nurses' station call light monitoring panel did not show these rooms as alarming. Interviews with Nurse Aides revealed that the monitoring panel was unreliable, with one stating, 'That doesn't work,' and another indicating it was 'hit or miss if it works.' The Director of Nursing confirmed the failure to maintain the call light equipment, which affected the residents' ability to signal for assistance effectively.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as being at risk for elopement. The resident, who had diagnoses of diabetes and coronary artery disease, was assessed as being at risk for elopement on 2/4/24. Despite this assessment, the resident was able to exit the building through an alarmed door, which was reset by a staff member who mistakenly assumed the alarm was triggered by an ambulance crew. The resident was later found by the Social Service Director near a gas station and expressed a desire not to return to the facility, exhibiting signs of mental distress and making threats of self-harm. The police were called, and the resident was transported to a hospital for a mental health evaluation. The incident revealed that the facility's procedures for monitoring and preventing elopement were not effectively implemented. The staff failed to properly respond to the door alarm, allowing the resident to leave the premises unnoticed. The facility's investigation confirmed that the resident exited through the ambulance entrance hallway and was not seen by the receptionist. This lapse in supervision and failure to follow elopement prevention protocols led to the resident's elopement and subsequent mental health crisis.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,139 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Huntingdon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kadima Rehabilitation & Nursing At Irwin | 2.8 mi | ★★★★★ | 15 | 0 |
| Hempfield Manor | 6.4 mi | ★★★★★ | 20 | 0 |
| Westmoreland Manor | 7.3 mi | ★★★★★ | 9 | 0 |
| William Penn Care Center | 7.4 mi | ★★★★★ | 15 | 0 |
| Redstone Highlands Health Care | 7.7 mi | ★★★★★ | 15 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.