Pennsylvania Department of Health
TRANSITIONS HEALTHCARE NORTH HUNTINGDON
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TRANSITIONS HEALTHCARE NORTH HUNTINGDON
Inspection Results For:

There are 165 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


TRANSITIONS HEALTHCARE NORTH HUNTINGDON - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on an Abbreviated Survey in response to one incident and two complaints, completed on March 11, 2026, it was determined that Transitions Healthcare North Huntingdon was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations: Based on review of facility policy, facility records, resident and staff interviews, it was determined that the facility failed to make certain call lights were accessible and answered timely for six of thirteen residents as required (Resident R1, R2, R3, R4, R5, and R6). Findings include: The facility policy "Call Bells" dated 4/1/25, indicated the purpose of this procedure is to respond to the resident's requests and needs when using the call bell system for assistance. If answering the call light from the nurse's station, please ensure that staff respond to resident request immediately. The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of Resident R1's clinical record indicated admission to the facility on 6/8/25. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/26, indicated diagnoses of adjustment disorder mental health condition intense of emotional and behavioral symptoms), diabetes mellitus (body cannot properly use or make insulin), and hypertension (high blood pressure) a BIMS of 12. Review of Section GG: Functional Abilities GG0130, indicated that Resident R1 is supervision or touching assistance with toileting hygiene, (helper provides verbal cues and or touching/steadying and/or contact guard assistance) and GG0170 toilet transfers requires substantial/maximal assistance, (helper does more than have the effort). During an interview and observation on 3/11/26, at approximately 11:00 a.m. Resident R1 stated she uses the call light when she needs help. "It takes a half hour or more to get help it can take more than an hour. What can you do, just keep pushing the button and eventually someone will come. Review of Resident R2's clinical record indicated admission to the facility on 7/22/24. Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/6/26, indicated diagnoses of hypertensive chronic kidney disease (kidney damage from long term high blood pressure), adjustment disorder mental health condition intense of emotional and behavioral symptoms), and hypertension (high blood pressure) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R2 is partial/moderate assistance, with toileting hygiene (helper does less than half the effort) and GG0170 toilet transfers, unable due to medical condition. During an interview and observation on 3/11/26, at approximately 11:10 a.m. Resident R2 stated she uses the call light when she needs help. "It takes a half hour and sometimes a lot longer than that to get help when you use your light." Review of Resident R3's clinical record indicated admission to the facility on 10/21/25. Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/20/26, indicated diagnoses of osteomyelitis of vertebra (infection in the bones of the spine), bipolar disorder (significant mood swings hypomanic and depressive), and hypertension (high blood pressure) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R3 is partial/moderate assistance, with toileting hygiene (helper does less than half the effort) and GG0170 toilet transfers requires partial/moderate assistance, (helper does less than half the effort). During an interview and observation on 3/11/26, at approximately 11:20 a.m. Resident R3 stated she uses the call light when she needs help. "It takes thirty minutes at a minimum, the other day I waited from 11:45 a.m. to 1:15 p.m." Review of Resident R4's clinical record indicated admission to the facility on 5/4/21. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/5/26, indicated diagnoses of chronic obstructive pulmonary disease (COPD disease that blocks airflow to the lungs), diabetes mellitus (body cannot properly use or make insulin), and depression, a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R4 is partial/moderate assistance, with toileting hygiene (helper does less than half the effort) and GG0170 toilet transfers is supervision or touching assistance with toileting hygiene, (helper provides verbal cues and or touching/steadying and/or contact guard assistance). During an interview and observation on 3/11/26, at approximately 11:30 a.m. Resident R4 stated she uses the call light when she needs help. Resident R4 stated you always have to wait sometimes only thirty minutes other times it is much longer. Review of Resident R5's clinical record indicated admission to the facility on 4/3/25 and discharged 1/30/26. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/19/25, indicated diagnoses of traumatic brain injury (brain injury which can lead to temporary or permanent changes in brain function , end stage renal disease (kidneys lose ability to function adequately requiring dialysis), and diabetes mellitus (body cannot properly use or make insulin) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R5 is dependent with toilet hygiene (helper does all the effort) and GG0170 toilet transfers, dependent (helper does all the effort). During a review of resident grievances, Resident R5 filed a grievance on 12/31/25 documenting his experiences and hours waiting for his brief to be changed after calling for assistance. Review of Resident R6's clinical record indicated admission to the facility on 2/15/26. Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/21/26, indicated diagnoses of hypertension (high blood pressure), heart failure (heart is unable to pump enough blood to meet the body's needs for blood and oxygen), and chronic obstructive pulmonary disease (lung disease that blocks airflow making breathing difficult) a BIMS of 11. Review of Section GG: Functional Abilities GG0130, indicated that Resident R6 is substantial/maximal assistance with toileting hygiene, (helper does more than have the effort) and GG0170 toilet transfers requires substantial/maximal assistance, (helper does more than have the effort). During an interview and observation on 3/11/26, at approximately 11:40 a.m. Resident R6 stated she uses the call light when she needs help. Resident R6 stated you always have to wait when you need help, "I have waited so long on occasion I have even called 911 when it takes too long." During a review of the resident council minutes of 1/26/26 and 2/27/26 contained documentation of "calls bells are not being answered in a timely fashion". During an interview on 3/11/26 at 2:30 p.m. the Nursing Home Director and the Director of Nursing confirmed the facility failed to make certain call lights were accessible and answered timely. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. 28 Pa Code: 201.29 (I)(o) Resident rights.

Plan of Correction - To be completed: 04/09/2026

1. Resident R1 and R5 have been discharged from the facility. The DON will meet with residents R2, R3, R4 and R6 to share the plan on enhancing call bell response times.
2. A review of grievances for the past 3 months does not indicate any other residents that were affected. Staff will interview their gaurdian angel residents to assess baseline feedback on call bell response times
3. Education will be provided by the DON or designee to staff on timeliness of call bell response times as well as follow up if the individual who can't meet the residents need responses to the call light.
4.An audit will be conducted weekly x2 then monthly x2 by the DON or designee to ensure timeliness of answering residents call lights and meeting their need. Five ( 5) Resident interviews will be conducted per day to review if call bell response time has improved for 4 weeks. Results will be taken to QAPI for review of findings and further interventions if warranted.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations: Based on facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for three of thirteen residents (Resident R1, R5 and R7). Findings include: Review of the "Resident Rights" policy last reviewed 4/1/25, indicated that the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of Resident R1's clinical record indicated admission to the facility on 6/8/25. Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/26, indicated diagnoses of adjustment disorder mental health condition intense of emotional and behavioral symptoms), diabetes mellitus (body cannot properly use or make insulin), and hypertension (high blood pressure) a BIMS of 12. Review of Section GG: Functional Abilities GG0130, indicated that Resident R1 is supervision or touching assistance with toileting hygiene, (helper provides verbal cues and or touching/steadying and/or contact guard assistance) and GG0170 toilet transfers requires substantial/maximal assistance, (helper does more than have the effort). During an interview and observation on 3/11/26, at approximately 11:00 a.m. Resident R1 stated the facility makes her use a bedpan when she needs to move her bowels. I have an order for the staff to get me up to the bedside commode, but they won't do it anymore. One day the bedside commode was taken out of my room and has never returned. I have asked and they just told me to use the bedpan. I would prefer to use the bedside commode. During a review of Resident R1 clinical record did reveal a physician ongoing order dated 7/4/25 for "patient to utilize bedside commode, at bedside in room, with an assist x2 for functional transfers." Review of Resident R5's clinical record indicated admission to the facility on 4/3/25 and discharged 1/30/26. Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/19/25, indicated diagnoses of traumatic brain injury (brain injury which can lead to temporary or permanent changes in brain function , end stage renal disease (kidneys lose ability to function adequately requiring dialysis), and diabetes mellitus (body cannot properly use or make insulin) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R5 is dependent on toilet hygiene (helper does all the effort) and GG0170 toilet transfers, dependent (helper does all the effort). During a review of grievances, Resident R5 filed a grievance on 12/31/25 documenting his experiences and hours waiting for his brief to be changed after calling for assistance. "I called for a nurse multiple times. I spoke to a nurse aide around 4:30 p.m. she said she would be back but didn't come back until after the incident was over and apologized. I texted my daughter at 7:38 p.m. and asked her to call the facility for me. My daughter called and spoke with a staff member who said she would handle it right away. The nurse came in but then it took another 30-40 minutes to find an aide to change me. I went from 9:30 a.m. to 8:30 p.m. without having my brief changed." Review of Resident R7's clinical record indicated admission to the facility on 5/17/25 Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/19/25, indicated diagnoses of traumatic brain injury (brain injury which can lead to temporary or permanent changes in brain function , end stage renal disease (kidneys lose ability to function adequately requiring dialysis), and diabetes mellitus (body cannot properly use or make insulin) a BIMS of 15. Review of Section GG: Functional Abilities GG0130, indicated that Resident R7 requires substantial/maximal assistance, (helper does more than have the effort) and GG0170 toilet transfers, not attempted, resident was unable to perform this activity prior to admission. During a review of grievances, Resident R7 filed a grievance on 12/23/25 documenting her experience. I was placed on the bedpan at 10:15 p.m. fell asleep and woke up at 11:43 and was still on the bed pan. Resident called for staff and had bedpan removed. During an interview on 3/11/26 at 2:30 p.m. the Nursing Home Director and the Director of Nursing confirmed the facility failed to make certain that care was provided in a manner which maintained resident dignity. 28 Pa. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(a) Resident rights.

Plan of Correction - To be completed: 04/09/2026

1. Resident R1 and R5 have been discharged from the facility. A new bowel and bladder assessment will be completed on R7 to evaluate current toileting needs
2. A review of grievances for the past 3 months does not indicate any other residents that were affected.
3. Education will be provided by the DON or designee to clinical staff on timeliness of meeting resident toileting needs which includes monitoring on and off times of bed pans placement
4.An audit will be conducted weekly x2 then monthly x2 by the DON or designee to ensure timeliness of meeting residents' toileting needs. Five (5) Resident interviews will be conducted per day to review if resident's toileting needs are met. Results will be taken to QAPI for review of findings and further interventions if warranted.

Five (5) Resident interviews will be conducted per day to review if resident's toileting needs are met weekly for 4 weeks.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement