Inspection Reports for Transitions Healthcare Washington Pa

90 HUMBERT LANE,, PA, 15301

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Deficiencies (last 5 years)

Deficiencies (over 5 years) 13.4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

185% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/year

Deficiencies per year

24 18 12 6 0
2021
2022
2023
2024
2025

Census

Latest occupancy rate 65% occupied

Based on a September 2025 inspection.

This facility has shown a steady increase in demand based on occupancy rates.

Census over time

10 20 30 40 50 60 Apr 2021 Sep 2022 Oct 2023 Oct 2024 Apr 2025 Sep 2025
Inspection Report Renewal Census: 31 Capacity: 48 Deficiencies: 2 Sep 9, 2025
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation at the facility.
Findings
The submitted plan of correction was found to be fully implemented. Two deficiencies were noted: an uncovered trash can in a resident bathing room and a discontinued medication still present in the medication cart, both of which were corrected with education and audits.
Complaint Details
The inspection included a complaint investigation component; however, the plan of correction was accepted and fully implemented, indicating resolution of the complaint issues.
Deficiencies (2)
Description
Uncovered trash can in resident bathing room, violating requirement for covered trash receptacles to prevent insect and rodent penetration.
Discontinued medication (Nystatin 100,000 unit/gm powder) still present in medication cart after prescriber discontinued it.
Report Facts
License Capacity: 48 Residents Served: 31 Current Residents in Hospice: 4 Residents Age 60 or Older: 30 Residents Diagnosed with Mental Illness: 17 Residents with Mobility Need: 3 Total Daily Staff: 34 Waking Staff: 26
Inspection Report Complaint Investigation Census: 31 Capacity: 48 Deficiencies: 1 Apr 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations related to staffing and medication administration.
Findings
The facility was found to routinely lack a qualified staff person to administer medications during the overnight shift despite having residents who cannot self-administer prescribed PRN medications. A plan of correction was accepted and fully implemented by June 16, 2025.
Complaint Details
The visit was complaint-related, with the reason explicitly stated as 'Complaint'. The submitted plan of correction was fully implemented as of June 16, 2025.
Deficiencies (1)
Description
The home routinely does not have a staff person present in the home who is qualified to administer medications during the 11:00pm through 7:30am shift, despite residents unable to self-administer prescribed PRN medications.
Report Facts
License Capacity: 48 Residents Served: 31 Current Residents in Hospice: 6 Residents Receiving Supplemental Security Income: 1 Residents Diagnosed with Mental Illness: 5 Residents with Mobility Need: 7 Residents Age 60 or Older: 30
Inspection Report Follow-Up Census: 30 Capacity: 48 Deficiencies: 2 Mar 11, 2025
Visit Reason
The inspection visit on 03/11/2025 was conducted as a complaint investigation and a follow-up to verify the implementation of the submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to the storage and locking of poisonous materials. Specific deficiencies regarding unlabeled and unlocked poisonous materials were corrected, and staff education and weekly audits were established to maintain compliance.
Complaint Details
The inspection was complaint-related, with the reason for the visit explicitly stated as 'Complaint'. The plan of correction was accepted and fully implemented as of the follow-up inspection date.
Deficiencies (2)
Description
Spray bottle containing approximately 250 mls of green liquid in an unlocked, unattended housekeeping cart without a manufacturer's label.
Housekeeping cart containing unlocked poisonous materials including Lysol multi-surface cleaner and aerosol spray can of glass cleaner accessible to residents who are not assessed as able to safely use or avoid poisonous materials.
Report Facts
License Capacity: 48 Residents Served: 30 Current Hospice Residents: 6 Staffing Hours - Resident Support Staff: 0 Staffing Hours - Total Daily Staff: 33 Staffing Hours - Waking Staff: 25 Spray Bottle Volume: 250 Lysol Multi-Surface Cleaner Volume: 118
Inspection Report Renewal Census: 28 Capacity: 48 Deficiencies: 10 Nov 13, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 11/13/2024 to review compliance with licensing requirements for Transitions Healthcare Washington PA.
Findings
The inspection identified multiple deficiencies including improper placement of carbon monoxide detectors, uncovered trash receptacles, unlabeled leftover food, incomplete fire drill records, medication labeling and administration errors, and failure to follow prescriber's orders. Plans of correction were accepted and implemented by 12/13/2024 with ongoing audits and staff training scheduled.
Deficiencies (10)
Description
Carbon monoxide detector in electrical room was mounted too close (2 feet) to natural gas furnaces, and no detector was present within 15 feet of gas cooking range-top.
Trash can in shared bathroom was not covered.
Leftover yellow gelatin in kitchen walk-in cooler was not labeled or dated.
Fire drill records did not indicate whether drills were held in 'a.m.' or 'p.m.'.
Sleeping hours fire drills were not held at required intervals.
Only one exit route ('A') was used during fire drills instead of alternate routes.
Pharmacy label for resident medication did not match prescribed dosage instructions.
Medication administration records showed discrepancies in blood glucose readings and documentation.
Medication administration times were not documented at the time of administration; refusals were not documented.
The home was splitting tablets that were not scored to be split, contrary to prescriber's orders.
Report Facts
License Capacity: 48 Residents Served: 28 Current Residents in Hospice: 6 Residents 60 Years or Older: 27 Residents Diagnosed with Mental Illness: 20 Residents with Mobility Need: 7
Employees Mentioned
NameTitleContext
Clinical CoordinatorNamed in multiple medication-related findings and plans of correction
Dietary ManagerNamed in leftover food finding and plan of correction
Regional Clinical NurseNamed in medication labeling and documentation training and plans of correction
AdministratorNamed in multiple findings related to fire drills, audits, and overall compliance oversight
Inspection Report Complaint Investigation Census: 26 Capacity: 48 Deficiencies: 3 Oct 23, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse at the facility.
Findings
The investigation found verbal abuse by staff towards a resident that was not immediately reported as required. Staff involved resigned, and corrective actions including education, supervision plans, and audits were implemented to prevent recurrence.
Complaint Details
The complaint investigation substantiated verbal abuse by staff persons A and B towards a resident at approximately 4:30am. The abuse was not reported until hours later, and staff person A continued working unsupervised after the incident. Both staff resigned following the investigation.
Deficiencies (3)
Description
Failure to immediately report suspected abuse of a resident to the Area Agency on Aging.
Failure to immediately supervise or suspend a staff person involved in an alleged abuse incident.
Resident was verbally abused by staff, including being called derogatory names and threatened.
Report Facts
License Capacity: 48 Residents Served: 26 Current Hospice Residents: 5 Residents Diagnosed with Mental Illness: 15 Residents Aged 60 or Older: 25 Total Daily Staff: 33 Waking Staff: 25
Inspection Report Follow-Up Census: 26 Capacity: 48 Deficiencies: 1 Feb 12, 2024
Visit Reason
The inspection visit on 02/12/2024 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection date. The facility addressed a prior abuse violation involving misappropriation of resident property, including staff termination and resident reimbursement.
Deficiencies (1)
Description
A resident was subjected to misappropriation of property by a staff member who rummaged through personal belongings and attempted unauthorized purchases. The staff member was terminated following investigation.
Report Facts
License Capacity: 48 Residents Served: 26 Current Residents in Hospice: 3 Residents Age 60 or Older: 24 Residents Diagnosed with Mental Illness: 8 Residents with Mobility Need: 8 Total Daily Staff: 34 Waking Staff: 26
Inspection Report Follow-Up Census: 22 Capacity: 48 Deficiencies: 1 Oct 27, 2023
Visit Reason
The visit was a follow-up inspection to verify that the submitted plan of correction was fully implemented following a complaint and incident.
Findings
The plan of correction related to a resident altercation and abuse was found to be fully implemented. Continued compliance is required to maintain standards.
Complaint Details
The inspection was complaint-related and involved an incident of resident abuse. The plan of correction was accepted and fully implemented.
Deficiencies (1)
Description
A physical altercation occurred between two residents, involving hitting and kicking, violating abuse prevention regulations.
Report Facts
License Capacity: 48 Residents Served: 22 Current Residents in Hospice: 2 Residents Diagnosed with Mental Illness: 11 Residents Aged 60 or Older: 22 Residents with Mobility Need: 7 Residents with Physical Disability: 1 Residents Receiving Supplemental Security Income: 1
Inspection Report Plan of Correction Census: 22 Capacity: 48 Deficiencies: 1 Oct 13, 2023
Visit Reason
The inspection was conducted due to an incident and included a review of the submitted plan of correction related to financial record-keeping for resident funds.
Findings
The facility was found to have a deficiency in maintaining records of financial transactions for resident funds, specifically a lack of documentation for withdrawals made from a resident's bank account. The submitted plan of correction was reviewed and determined to be fully implemented.
Deficiencies (1)
Description
No record of financial transactions for resident #1 despite withdrawals made from their bank account.
Report Facts
License Capacity: 48 Residents Served: 22 Current Residents in Hospice: 2 Residents Receiving Supplemental Security Income: 1 Residents Diagnosed with Mental Illness: 11 Residents Aged 60 or Older: 22 Residents with Mobility Need: 7 Residents with Physical Disability: 1
Inspection Report Complaint Investigation Census: 22 Capacity: 48 Deficiencies: 3 Aug 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction.
Findings
The inspection found deficiencies related to unsecured poisonous materials accessible to residents, broken and rusted gate on the walkway, and cracked deteriorated sidewalk areas presenting hazards. All identified issues were corrected with removal or repair and staff education was provided.
Complaint Details
The inspection was triggered by a complaint, and the plan of correction submitted was fully implemented and accepted.
Deficiencies (3)
Description
Three one-gallon buckets of paint, primer, and spackling were left unlocked and accessible in a vacant resident room, posing a poisoning hazard.
The steel gate with chain-link fencing on the walkway was rusted and broken, preventing proper opening and posing a hazard.
The sidewalk leading to the home's pavilion was cracked and deteriorated in three areas, creating tripping hazards.
Report Facts
License Capacity: 48 Residents Served: 22 Current Residents in Hospice: 2 Residents Diagnosed with Mental Illness: 7 Residents 60 Years or Older: 22 Residents with Mobility Need: 5 Residents Receiving Supplemental Security Income: 1
Inspection Report Renewal Census: 20 Capacity: 48 Deficiencies: 4 Feb 10, 2023
Visit Reason
The inspection was conducted as a licensing inspection including renewal, complaint, and provisional reasons on February 10 and 13, 2023.
Findings
The facility was found to be in compliance overall, but several deficiencies were identified including failure to complete a criminal background check for a direct care staff member, improper food storage with unsealed containers and outdated food items, and medication labeling discrepancies for two residents. Plans of correction were accepted and implemented.
Deficiencies (4)
Description
Direct Care Staff person did not have a criminal background check completed by the Pennsylvania State Police.
Multiple containers of unsealed food in the freezer and refrigerator, exposing food.
Outdated or spoiled food items found in unsealed bags inside the commercial freezer.
Medication labels on pill packs did not match the prescribed medications for two residents.
Report Facts
License Capacity: 48 Residents Served: 20 Staff Total Daily: 22 Waking Staff: 17
Inspection Report Monitoring Census: 20 Capacity: 48 Deficiencies: 3 Sep 15, 2022
Visit Reason
The inspection was a monitoring visit conducted on September 15, 2022, to assess compliance with regulations and review the facility's corrective actions.
Findings
The inspection found deficiencies related to inadequate staffing during night shifts to safely evacuate residents, failure to evacuate all residents during multiple fire drills, and failure to conduct fire drills with minimum staffing as required. Plans of correction were submitted but not implemented as of the follow-up dates.
Deficiencies (3)
Description
On 9/14/22, only one direct care staff was present from 11:00pm to 7:00am, inadequate to safely evacuate all residents, including 3 with mobility needs requiring two staff for transfer.
The home did not evacuate all residents during multiple fire drills on various dates and times, failing to meet the maximum evacuation time of 6 minutes 30 seconds.
The home has not conducted a fire drill with only 2 staff persons during the 11:00pm to 7:00am shift within the past year, contrary to regulations.
Report Facts
Residents present during inspection: 20 Licensed capacity: 48 Residents with mobility needs: 3 Staff present during night shift: 1 Fire drill evacuation counts: 17 Fire drill evacuation counts: 4 Fire drill evacuation counts: 12 Fire drill evacuation counts: 21 Fire drill evacuation counts: 20 Maximum evacuation time: 390 Evacuation time recorded: 408
Employees Mentioned
NameTitleContext
Joyce ReedyAdministratorNamed as Administrator responsible for staffing and compliance
Jamie BuchenauerDeputy Secretary, Office of Long-term LivingSigned the provisional license letter
Inspection Report Renewal Census: 23 Capacity: 48 Deficiencies: 23 Apr 19, 2022
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation, with an unannounced full inspection from 04/19/2022 to 04/21/2022.
Findings
The inspection identified multiple deficiencies including abuse by a staff member, inadequate staffing levels, failure to maintain sanitary conditions, missing emergency procedures, incomplete fire drill records, and lack of a resident activity program. Plans of correction were accepted or directed with specific completion dates.
Complaint Details
The inspection included a complaint investigation related to allegations of abuse and mistreatment by staff person B, which was substantiated leading to suspension and termination of the staff member.
Deficiencies (23)
Description
Quality management plan was outdated, last review in April 2020.
Resident abuse by staff person B including inappropriate touching and verbal mistreatment.
Staff person B made inappropriate sexual comments to residents.
Inadequate personal care staffing hours provided on 4/9/22, less than required hours for residents with mobility needs.
Only one staff person present during night shift (11 PM to 7 AM) on multiple dates, insufficient for safe evacuation.
Staff person A did not receive required orientation on fire safety and resident rights within required timeframes.
No paper towels or other sanitary hand drying means in some resident bathrooms.
No lighting present at evacuation route near exit door by bedroom #118.
Water damage and peeling paint on ceiling and wall near exit door by bedroom #118.
Walkie-talkies available but not used by staff for communication.
No emergency telephone numbers posted near telephone in bedroom #131.
Resident #5's bed was inoperable and repaired.
Missing chairs in bedrooms of residents #2, #3, #6, and #7.
Bedside lamps for residents #6, #7, and #8 were not operable from bedside.
No soap in dispenser in resident #1's bathroom; unlabeled bar soap in bathrooms of residents #2, #3, #6, and #7.
Use of common towels observed in bathrooms of residents #2, #3, #6, and #7.
Emergency procedures not posted in a conspicuous and public place.
Resident #8 with hearing impairment not provided with approved signaling device for fire alarm.
Fire safety inspection and fire drill by fire safety expert not completed within past year.
Fire drill records incomplete, missing key information such as evacuation times, number of residents and staff, exit routes, and alarm operability.
No program of activities to promote resident involvement with families and community.
Resident #1's initial assessment not completed within 15 days of admission.
Residents #7 and #9 had outdated assessments not reflecting current assistance needs.
Report Facts
Residents served: 23 License capacity: 48 Staffing hours required: 29 Staffing hours provided: 28 Staffing hours during waking hours required: 21.75 Staffing hours during waking hours provided: 20.5 Staff persons on night shift: 1 Residents with mobility needs: 7 Residents diagnosed with mental illness: 5 Hospice residents: 1
Employees Mentioned
NameTitleContext
Staff person BNursing Home AdministratorNamed in multiple abuse and mistreatment findings leading to suspension and termination
Staff person ANamed in findings related to failure to receive required orientation training
Inspection Report Routine Deficiencies: 0 Aug 13, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice Capacity: 48 Deficiencies: 0 Jul 7, 2021
Visit Reason
The document serves as a certificate of compliance and a renewal notice for the Personal Care Home license. It informs the facility that the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application and advises that future inspections will be conducted to ensure compliance.
Report Facts
Maximum capacity: 48
Employees Mentioned
NameTitleContext
Jamie L. BuchenauerDeputy Secretary, Office of Long-term LivingSigned the renewal notice letter
Inspection Report Renewal Census: 21 Capacity: 48 Deficiencies: 9 Jun 9, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing requirements for the facility.
Findings
The inspection identified multiple deficiencies including improper placement of a carbon monoxide detector, incomplete fire safety orientation for a new staff member, unlabeled personal care items in the shower room, water damaged ceiling tiles and peeling wallpaper in resident rooms, missing functional thermometers in refrigeration units, lack of posted emergency procedures, presence of discontinued medication in the medication cart, absence of a current weekly activity calendar, and incomplete documentation in a resident's support plan. All deficiencies had plans of correction accepted and were implemented or scheduled for correction.
Deficiencies (9)
Description
Carbon monoxide detector was mounted approximately 4 feet from a natural gas fired hot water tank, violating placement standards.
Direct care staff person did not complete orientation in general fire safety and emergency preparedness on the first day of work.
Unlabeled personal care items including hair brush, antifungal cream, body wash, and shampoo found in common shower room.
Water damaged ceiling tiles and peeling wallpaper in multiple resident rooms.
No functional thermometer in refrigerator and walk-in freezer in the home's kitchen and dining room.
Emergency procedures for the municipality were not posted in a conspicuous and public place in the home.
Medication cart contained Loratadine 10 MG Tablet for resident #4 which was discontinued on 6/1/21.
No current weekly activity calendar posted in a public and conspicuous place; posted calendar was dated 05/21.
Resident #5's support plan did not document frequency or responsible party for management of constipation.
Report Facts
License Capacity: 48 Residents Served: 21 Staffing Hours: 25 Waking Staff: 19 Supplemental Security Income recipients: 3 Residents Age 60 or Older: 20 Residents Diagnosed with Mental Illness: 6 Residents with Mobility Need: 4
Inspection Report Follow-Up Census: 24 Capacity: 48 Deficiencies: 4 Apr 12, 2021
Visit Reason
The inspection was a partial, unannounced visit conducted due to an incident, to review compliance and citations at the facility.
Findings
The inspection found deficiencies related to inadequate assistance with activities of daily living, insufficient staffing during night hours, unsanitary conditions including food debris and uncovered trash receptacles. Plans of correction were accepted and documented as implemented or ongoing.
Deficiencies (4)
Description
Resident #1 did not receive toileting assistance at the frequency indicated in the support plan.
Staffing was insufficient between 11:00 p.m. and 7:00 a.m. with only one staff member present despite resident needs.
Layering of food crumbs and other detritus on the floor surrounding resident #1’s bed and in the shared bathroom.
Trash can in the bathroom for residents #1 and #2 was uncovered and approximately half-full; a full open bag of trash was on the floor near the shower.
Report Facts
Residents served: 24 License capacity: 48 Residents with mobility needs: 6 Residents requiring 2-person assist: 1 Staff on duty: 1 Total daily staff: 30 Waking staff: 23 Residents receiving Supplemental Security Income: 3 Residents diagnosed with mental illness: 8 Residents aged 60 or older: 24 Residents with physical disability: 1
Inspection Report Renewal Deficiencies: 0 Jan 7, 2021
Visit Reason
The inspection was conducted as part of the licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 01/07/2021 and 01/08/2021 for the facility Transitions Healthcare Washington PA LLC.
Findings
No regulatory citations were identified as a result of this inspection.

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