Inspection Reports for
Transitions Healthcare Washington Pa
90 HUMBERT LANE,, WASHINGTON, PA, 15301
Back to Facility Profile33 Reports
Inspection Report — Sep 9, 2025
Renewal
Date: Sep 9, 2025
Visit Reason
The inspection was conducted as a renewal inspection combined with a complaint investigation at the facility.
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.
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.
Citations (2)
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
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 — Apr 22, 2025
Complaint Investigation
Date: Apr 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations related to staffing and medication administration.
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.
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.
Citations (1)
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
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 — Mar 11, 2025
Follow-Up
Date: 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.
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.
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.
Citations (2)
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
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 — Nov 13, 2024
Renewal
Date: 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.
Citations (10)
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
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
| Name | Title | Context |
|---|---|---|
| Clinical Coordinator | Named in multiple medication-related findings and plans of correction | |
| Dietary Manager | Named in leftover food finding and plan of correction | |
| Regional Clinical Nurse | Named in medication labeling and documentation training and plans of correction | |
| Administrator | Named in multiple findings related to fire drills, audits, and overall compliance oversight |
Inspection Report — Oct 23, 2024
Complaint Investigation
Date: Oct 23, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations of resident abuse at the facility.
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.
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.
Citations (3)
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
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 — Feb 12, 2024
Follow-Up
Date: 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.
Citations (1)
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
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 — Oct 27, 2023
Follow-Up
Date: 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.
Complaint Details
The inspection was complaint-related and involved an incident of resident abuse. The plan of correction was accepted and fully implemented.
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.
Citations (1)
A physical altercation occurred between two residents, involving hitting and kicking, violating abuse prevention regulations.
Report Facts
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 — Oct 13, 2023
Plan of Correction
Date: 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.
Citations (1)
No record of financial transactions for resident #1 despite withdrawals made from their bank account.
Report Facts
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 — Aug 3, 2023
Complaint Investigation
Date: Aug 3, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance and verify the submitted plan of correction.
Complaint Details
The inspection was triggered by a complaint, and the plan of correction submitted was fully implemented and accepted.
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.
Citations (3)
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
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 — Feb 10, 2023
Renewal
Date: 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.
Citations (4)
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
Residents Served: 20
Staff Total Daily: 22
Waking Staff: 17
Inspection Report — Feb 10, 2023
Renewal
Date: Feb 10, 2023
Visit Reason
The inspection was conducted as part of the licensing inspections on February 10 and 13, 2023, to determine compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes and to issue a regular license.
Findings
The facility was found to be in compliance with the applicable regulations after corrections were made following the inspection. A regular license was issued.
Notice — Nov 21, 2022
Date: Nov 21, 2022
Visit Reason
The letter informs the facility of the revocation of their certificate of compliance due to violations found during licensing inspections on April 19, 20, 21, and September 15, 2022, and the issuance of a first provisional license based on an acceptable plan of correction.
Findings
Violations of 55 Pa. Code Chapter 2600 related to Personal Care Homes were found during multiple licensing inspections, leading to revocation of the previous license and issuance of a provisional license contingent on correction of these violations.
Report Facts
Inspection dates: Licensing inspections conducted on April 19, 2022, April 20, 2022, April 21, 2022, and September 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the letter notifying the facility of license revocation and provisional license issuance |
Inspection Report — Sep 15, 2022
Monitoring
Date: 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.
Citations (3)
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
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
| Name | Title | Context |
|---|---|---|
| Joyce Reedy | Administrator | Named as Administrator responsible for staffing and compliance |
| Jamie Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the provisional license letter |
Inspection Report — Apr 19, 2022
Renewal
Date: 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.
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.
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.
Citations (23)
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
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
| Name | Title | Context |
|---|---|---|
| Staff person B | Nursing Home Administrator | Named in multiple abuse and mistreatment findings leading to suspension and termination |
| Staff person A | Named in findings related to failure to receive required orientation training |
Inspection Report — Aug 13, 2021
Routine
Date: 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 — Jul 7, 2021
Date: 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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notice letter |
Inspection Report — Jun 9, 2021
Renewal
Date: 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.
Citations (9)
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
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 — Apr 12, 2021
Follow-Up
Date: 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.
Citations (4)
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
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 — Jan 7, 2021
Renewal
Date: 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.
Inspection Report — Mar 12, 2020
Complaint Investigation
Date: Mar 12, 2020
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial inspection on March 12, 2020.
Complaint Details
The inspection was triggered by a complaint and was unannounced. The plan of correction was approved and fully implemented as of May 8, 2020.
Findings
The facility was found to have a non-functioning ventilation fan in the bathroom of resident room 109, which lacked an operable window. The submitted plan of correction was reviewed and determined to be fully implemented.
Citations (1)
2600.86.b Bathroom ventilation fan in resident room 109 is inoperable and there is no window in this bathroom. The ventilation fan was replaced and is now functioning properly.
Report Facts
Residents Served: 33
Current Hospice Residents: 3
Inspection Report — Oct 10, 2019
Renewal
Date: Oct 10, 2019
Visit Reason
The inspection was conducted as a renewal inspection of Transitions Healthcare Washington PA on October 10 and October 16, 2019.
Findings
The inspection identified multiple violations including issues with resident personal equipment, trash outside the home, furniture and equipment repair, walls/floors/ceilings condition, unobstructed egress, furnace inspections, evacuation times, fire drills during sleeping hours, and smoking area guidelines. All violations had plans of correction implemented by February 5, 2020.
Citations (9)
2600.81b. Wheelchairs, walkers, prosthetic devices and other apparatus used by residents must be clean, in good repair and free of hazards. Resident #1's enabler had an uncovered pocket posing an entrapment hazard and residents #2 and #3 had cracked wheelchair armrests posing skin tear hazards.
2600.85e. Trash outside the home shall be kept in covered receptacles to prevent insect and rodent penetration. Two large dumpsters were overflowing with trash bags preventing lids from closing and approximately 40 trash bags were on the ground next to dumpsters.
2600.95. Furniture and equipment must be in good repair, clean and free of hazards. The faucet in room 106 was loose and the cold water set-screw was missing.
2600.101o. Bedrooms must have walls, floors and ceilings that are finished, clean and in good repair. Two ceiling tiles near the sprinkler head in room 107 had water stains approximately 12" by 12" in a triangular shape.
2600.121a. Stairways, hallways, doorways, passageways and egress routes must be unlocked and unobstructed. Furniture and multiple items blocked hallways leading to emergency exits including hospital beds, lounge chair, mattresses, ladder, hand truck, tray table, and rollator walker.
2600.126a. Furnaces must be inspected at least annually by a professional or trained maintenance staff. No furnace inspections were documented for two electric furnaces in the med tech room in the past year.
2600.132d. Residents must be able to evacuate the building to a safe area within a time specified by a fire safety expert. The home exceeded safe evacuation times during fire drills on 2/28/19, 3/31/19, and 9/30/19 with times of 8, 7, and 8 minutes respectively.
2600.132e. A fire drill shall be held during sleeping hours once every 6 months. No sleeping hours fire drills were conducted in the past 12 months.
2600.144c. A home permitting smoking must have written fire safety policies including proper disposal of cigarette butts. The outside designated smoking area had an overflowing ashtray and approximately 30 cigarette butts on the ground.
Report Facts
Residents Served: 33
Current Hospice Residents: 4
Resident Support Staff: 0
Total Daily Staff: 43
Waking Staff: 32
Supplemental Security Income: 2
Residents Age 60 or Older: 33
Residents Diagnosed with Mental Illness: 7
Residents with Mobility Need: 10
Residents with Physical Disability: 2
Cigarette Butts: 30
Trash Bags: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Wright | Administrator | Named in multiple plans of correction and signature on violation reports |
Inspection Report — Apr 11, 2019
Renewal
Date: Apr 11, 2019
Visit Reason
The document is a renewal application and license issuance for Transitions Healthcare Washington PA to operate a Personal Care Home, with the Department required to conduct an onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal notification and states that an inspection will be conducted within the next year.
Inspection Report — Mar 26, 2019
Routine
Date: Mar 26, 2019
Visit Reason
The Department’s Bureau of Human Services Licensing conducted an inspection of the facility to assess compliance with 55 Pa. Code Ch. 2600 relating to Personal Care Homes.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Inspection Report — Nov 6, 2018
Complaint Investigation
Date: Nov 6, 2018
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged resident neglect and mistreatment.
Complaint Details
The complaint was substantiated based on the incident where staff person A neglected and verbally abused resident #1. The plan of correction included suspension and termination of the employee, staff education, and enhanced reporting procedures.
Findings
The investigation found that staff person A neglected and verbally abused resident #1 during a shower, resulting in the resident becoming incontinent and distressed. A plan of correction was developed including staff suspension, education on abuse identification and reporting, and criminal background checks for new hires.
Citations (1)
55 Pa.Code §2600 42(b): A resident was neglected, intimidated, and verbally abused by staff during a shower, causing distress and incontinence. Staff failed to provide appropriate care and engaged in slamming things around the resident's room.
Report Facts
Number of Residents Served: 30
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 3
Residents Age 60 or Older: 30
Residents with Mental Illness: 4
Residents with Mobility Need: 12
Residents with Physical Disability: 2
Residents Receiving Supplemental Security Income: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Hixenbaugh | Administrator | Signed plan of correction and involved in investigation |
| Michael Marini | Department representative conducting on-site inspection |
Inspection Report — Sep 5, 2018
Renewal
Date: Sep 5, 2018
Visit Reason
The inspection was conducted as an annual renewal inspection of Transitions Healthcare Washington PA to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including issues with unsecured medication storage, unsigned resident contracts, incomplete employee job descriptions, lack of required staff training documentation, and missing physician names on medical equipment documentation. Plans of correction were submitted with varying implementation statuses.
Citations (10)
2600.17: The nursing/administration room where medication information and medical evaluations are stored was unlocked, unattended, and accessible on 9/5/18.
2600.25(b): Resident contracts for residents 1, 2, and 3 were not signed by the residents; administrator will review and obtain signatures by 3/15/19.
2600.65(c): Job description for ancillary person A was located and signed, but staff person A is no longer employed; administration will review all employee job files for signatures by 3/15/19.
2600.65(l): Staff persons B and C did not receive required training on topics during the 2017 annual training year; administrator will monitor employee files quarterly for compliance.
2600.65(f): Staff persons B and C did not receive retroactive 2018 education; administrator will monitor employee files quarterly and maintain annual training logs.
2600.65(g): Staff person B will receive annual fire safety training by a qualified expert; administrator will schedule required annual trainings and maintain training logs for 2019.
2600.65(i): Administrator will record source, content, and length of each training course on DHS training logs and maintain employee sign records for 2019 and forward.
2600.141(b)(1): Administrator will educate physicians to print their names on medical professional information sections of durable medical equipment and review resident charts for compliance.
2600.191: Administrator will review resident records for Attachment D notice of Residents Rights, including right to refuse or question medication, and ensure documentation of resident #1's education on this right.
2600.162(c): Weekly dates were added to the menu for clarification; menus will be reviewed during resident counsel for education on usage.
Report Facts
Number of Residents Served: 31
Number of Current Hospice Residents: 1
Number of Hospice Residents in past year: 4
Residents Receiving Supplemental Security Income: 4
Residents Age 60 or Older: 31
Residents with Mental Illness: 6
Residents with Intellectual Disability: 0
Residents with Mobility Need: 7
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tammy Hixenbaugh | Administrator | Named in multiple findings and plans of correction |
Notice — Aug 6, 2018
Date: Aug 6, 2018
Visit Reason
The document is a waiver approval letter granting a waiver of Pennsylvania Code requirements for administrator training and orientation to allow completion of training to become a qualified personal care home administrator.
Findings
The waiver is granted with conditions including completion of orientation, passing a competency-based test, and submission of documentation by specified dates. The waiver expires on September 4, 2018, after which full compliance is expected.
Report Facts
Waiver expiration date: Sep 4, 2018
Scheduled orientation date: Aug 10, 2018
Scheduled competency test date: Aug 20, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Notice — Apr 17, 2018
Date: Apr 17, 2018
Visit Reason
The document serves as a renewal notification and license approval for Transitions Healthcare Washington PA LLC to operate a Personal Care Home. It also informs the facility administrator about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is an administrative license renewal notice with no deficiencies or compliance issues mentioned.
Report Facts
Inspection Report — Sep 20, 2017
Renewal
Date: Sep 20, 2017
Visit Reason
The inspection was conducted as an annual licensing inspection with reasons listed as renewal and complaint.
Findings
Two violations were found: failure to post influenza information as required by the Influenza Awareness Act, and incomplete initial assessments for two residents regarding adaptive equipment and hearing aids.
Citations (2)
55 Pa.Code 2600.18: Influenza information was not posted in the facility on 09/20/17 as required by the Influenza Awareness Act.
55 Pa.Code 2600.225(a): Initial assessments for residents #1 and #2 lacked documentation of wheeled walker, glasses, and hearing aids as required within 15 days of admission.
Report Facts
Number of Residents Served: 35
Resident Support Staff: 35
Total Daily Staff: 77
Waking Staff: 58
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 4
Residents Age 60 or Older: 35
Residents with Mental Illness: 6
Residents with Mobility Need: 7
Residents with Physical Disability: 1
Residents Receiving Supplemental Security Income: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wesley Robinson | Administrator | Named in plan of correction and violation report |
Notice — Sep 8, 2017
Date: Sep 8, 2017
Visit Reason
The document is a response to a request for a waiver of specific Pennsylvania Code regulations related to admission and resident medical evaluation for a licensed personal care home.
Findings
The waiver is granted under specified conditions including use of alternative documentation for medical evaluations. The waiver remains effective as long as conditions are met and will be reviewed annually during the facility's annual inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Inspection Report — May 1, 2017
Renewal
Date: May 1, 2017
Visit Reason
The document is a renewal application and license issuance for Transitions Healthcare Washington PA LLC to operate a Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as required by law.
Findings
No inspection findings are reported in this document. It primarily communicates the license renewal and the requirement for a future annual inspection.
Report Facts
Inspection Report — Aug 15, 2016
Annual Inspection
Date: Aug 15, 2016
Visit Reason
The inspection was an annual licensing inspection conducted on August 15 and 16, 2016, and November 28, 2016, for Transitions Healthcare Washington PA to assess compliance with 55 Pa.Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations were found related to resident confidentiality, admission paperwork, staff training, fire safety orientation, equipment maintenance, sanitation, and medication administration. Plans of correction were submitted and partially or fully implemented by January 4, 2017.
Citations (19)
55 Pa.Code 2600.17 - Resident records were unlocked, unattended, and accessible on the activities storage room desk.
55 Pa.Code 2600.25(a)(1) - Resident #3 was admitted without a completed written resident-home contract.
55 Pa.Code 2600.63(a) - No staff trained and certified in obstructed airway techniques and CPR were present during night shifts for 35 residents.
55 Pa.Code 2600.65(a) - Staff person A did not receive orientation in fire safety and emergency preparedness including evacuation procedures and use of fire extinguishers.
55 Pa.Code 2600.65(b) - Staff person A did not complete orientation in resident rights, emergency medical plan, mandatory abuse reporting, and incident reporting.
55 Pa.Code 2600.65(e) - Several direct care staff did not receive any hours of annual training in 2015.
55 Pa.Code 2600.65(g) - Several direct care staff did not receive annual training in fire safety, emergency preparedness, resident rights, abuse prevention, and falls prevention.
55 Pa.Code 2600.65(i) - Training record for staff person G did not include length of ethics and compliance training course.
55 Pa.Code 2600.81(b) - Wheelchair arms for residents #4 and #5 were cracked, torn, and exposing foam.
55 Pa.Code 2600.82(c) - Poisonous materials were unlocked and accessible to residents in the activities storage room.
55 Pa.Code 2600.85(a) - Dirt, cobwebs, and dead bugs were present in the emergency exit alcove and refrigerator with spoiled food and liquids.
55 Pa.Code 2600.85(d) - Trash cans in kitchens and bathrooms were uncovered or lacked lids.
55 Pa.Code 2600.102(d)(1) - Visitor and employee bathrooms lacked grab bars, hand rails, or assist bars.
55 Pa.Code 2600.103(f) - Refrigerators lacked working thermometers; temperature measured 68 degrees.
55 Pa.Code 2600.126(a) - No documentation of annual professional furnace inspection was available.
55 Pa.Code 2600.132(d) - The home lacked a written evacuation plan within the past year by a fire safety expert.
55 Pa.Code 2600.132(b) - Fire alarm or smoke detector was not set off during multiple fire drills.
55 Pa.Code 2600.183(b) - Prescription medications, OTC medications, CAM, and syringes were not locked in a secure area.
55 Pa.Code 2600.187(c) - Resident #1 refused prescribed glucometer readings which were not reported to the prescriber as required.
Report Facts
Number of Residents Served: 35
Number of Residents Served: 36
Total Daily Staff: 37
Walking Staff: 28
Total Daily Staff: 51
Walking Staff: 30
Number of Current Hospice Residents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wesley Robinson | Administrator | Named in multiple findings and plans of correction throughout the report |
Notice — May 12, 2016
Date: May 12, 2016
Visit Reason
The document serves as a renewal notification and license issuance for Transitions Healthcare Washington PA LLC to operate a Personal Care Home. It also informs about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice with no deficiencies or compliance issues mentioned.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jay Bausch | Deputy Secretary | Signed the renewal notification letter. |
Notice — June 10, 2020
Date: June 10, 2020
Visit Reason
This document serves as a renewal notification and license issuance for Transitions Healthcare Washington PA LLC to operate a Personal Care Home. It informs the facility that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
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