Pennsylvania Department of Health
TRANSITIONS HEALTHCARE AUTUMN GROVE CARE CENTER
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 49 surveys for this facility. Please select a date to view the survey results.

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TRANSITIONS HEALTHCARE AUTUMN GROVE CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on July 29, 2025, at Transitions Healthcare Autumn Grove Care Center, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #022102
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on July 29, 2025, it was determined that Transitions Healthcare Autumn Grove Care Center was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (000), unprotected, wood frame building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0100

Based on document review, observation, and interview, the facility failed to maintain portable floor plans that outlined designated rated partitions, affecting the basement of the facility.

Findings include:

Observation and document review on July 29, 2025, at 8:30 a.m., revealed the facility failed to provide a set of accurate, portable floor plans for the basement. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site to be used during the Life Safety Code Survey. The Life Safety Code Floor Plan failed to include the following:

a. Smoke barrier walls (outside wall to outside wall and enclosures)
b. Fire barrier walls (indicating 1-2 hour walls)
c. Horizontal exits
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan
e. Required exits should be clearly noted
f. Shaft walls

Interview with the maintenance supervisor on July 29, 2025, at 8:30 a.m., confirmed the facility's Life Safety Code Floor Plan was unavailable for the basement at the time of the survey.

Plan of Correction - To be completed: 09/12/2025

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.

The facility has hired an architect to draw up accurate floor plans for the basement to include the following:

a. Smoke barrier walls (outside wall to outside wall and enclosures)
b. Fire barrier walls (indicating 1-2 hour walls)
c. Horizontal exits
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan
e. Required exits should be clearly noted
f. Shaft walls

NFPA 101 STANDARD Doors with Self-Closing Devices:

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.

Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of:
* Required manual fire alarm system; and
* Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and
* Automatic sprinkler system, if installed; and
* Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0223

Based on observation and interview, the facility failed to maintain two of over ten self-closing doors.

Observation and interview on July 29, 2025, between 8:52 a.m. and 9:43 a.m., revealed the following deficiencies:

A.(8:52 a.m.) Main floor, at the A/B, storage room/corridor self-closing door failed to latch in the frame;
B.(9:43 a.m.) The basement level dryer room/corridor had a self-closing door that failed to latch in the frame.

Interview with the maintenance supervisor on July 29, 2025, at 9:43 a.m., confirmed the door deficiencies.

Plan of Correction - To be completed: 09/12/2025

The Main floor, at the A/B storage room/corridor self-closing door has been repaired.

The basement level dry room/corridor self-closing door will be replaced.

Audit will be done on all self closing doors.

Audit and Door replacements will be taken to Safety Committee for review/discussion.

NFPA 101 STANDARD Vertical Openings - Enclosure:

Vertical Openings - Enclosure
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this
box.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0311

Based on observation and interview, the facility failed to maintain self-closing vertical opening doors for one of two doors.

Findings include:

Observation on July 29, 2025, at 9:50 a.m., revealed the basement dumbwaiter door failed to self-close and latch in the frame.

Interview with maintenance supervisor on July 29, 2025, at 9:50 a.m., confirmed the dumbwaiter door deficiency.

Plan of Correction - To be completed: 09/12/2025

The basement dumbwaiter door was inspected on 6/28/29 and passed.

The door has a 1.5hr fire rating.

The dumbwaiter has a door in the basement and a door on the main floor. One door is always closed and latched. If the dumbwaiter is sitting on the main level, the basement door is closed and latched. When the dumbwaiter is moved to the basement, the main level door is closed and latched. Both doors are closed and latched when not in use.

Self closing hinges with double latch were installed on basement dumbwaiter door on 8/7/2025

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on document review, observation, and interview, the facility failed to meet sprinkler system maintenance and inspection requirements effecting the entire facility.

Findings include:

Document review on July 29, 2025 at 8:55 a.m. revealed the internal tank inspection completed on October 23, 2024 had listed the following deficiencies:
A. (8:55 a.m.) The interior coating system is currently 20 years old and showing major signs of failure, mainly in the 2nd and 3rd shell ring;
B. (8:55 a.m.) Interior drain line showing significant signs of coating failure.

Interview with the maintenance supervisor on July 29, 2025 at 8:55 a.m., confirmed the deficiencies listed above existed at the time of the survey and has a repair company scheduled to fix the deficiencies.

Based on observation and interview, the facility failed to maintain the sprinkler system on one of two floors.

Findings Include:

Observation on July 29, 2025, between 9:42 a.m. and 9:48 a.m., revealed sprinkler heads were covered with a layer of dust/lint in the following laundry rooms:

A. (9:42 a.m.) Basement laundry dryer room had two sprinkler heads that were dust-covered. A build-up of material can insulate the sprinkler thermal element, impacting the temperature activation/response time of the sprinkler and/or cause inadequate spray coverage.
B. (9:48 a.m.) The basement laundry folding room had four sprinkler heads that were dust-covered.

Interview with the maintenance supervisor on July 29, 2025, at 9:48 a.m., confirmed the sprinkler head deficiences.

Plan of Correction - To be completed: 08/26/2025

The repairs to the internal tank are scheduled to be completed by August 26, 2025

NFPA 101 STANDARD Combustible Decorations:

Combustible Decorations
Combustible decorations shall be prohibited unless one of the following is met:
o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product.
o Decorations meet NFPA 701.
o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289.
o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4).
o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present.
19.7.5.6

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0753

Based on observation and interview, the facility failed to maintain combustible decorations on two of over twenty doors.

Findings include:

Observation on July 29, 2025, between 8:58 a.m. and 9:14 a.m., revealed the following:

A. (8:58 a.m.) Main-floor resident room #210 corridor door had decorations that exceeded allowable coverage. The decorations also had no fire, flame, or smoke proofing documentation.

B. (9:14 a.m.) Main-floor resident room #308 corridor door had decorations that exceeded allowable coverage. The decorations also had no fire, flame, or smoke proofing documentation.

Interview with the maintenance supervisor on July 29, 2025, at 9:14 a.m., confirmed the combustible decoration deficiencies.

Plan of Correction - To be completed: 08/30/2025

A. Doors of room 210 and 308 will be sprayed with fire retardant spray.

B. All doors will be audited for decorations and sprayed with fire retardant spray.

C. An audit will be done on all doors weekly x4 weeks then monthly thereafter.

D. A log will be kept on all doors with decorations treated with fire resistant spray.

E. Audits will be reviewed at quarterly QAPI (Quality Assurance and Performance Improvement) meeting

NFPA 101 STANDARD Maintenance, Inspection & Testing - Doors:

Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.
Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability.
Written records of inspection and testing are maintained and are available for review.
19.7.6, 8.3.3.1 (LSC)
5.2, 5.2.3 (2010 NFPA 80)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0761

Based on observation and interview, the facility failed to meet door maintenance and inspection requirements on one of two building levels.

Findings include:

Observation on July 29, 2025, at 10:01 a.m., revealed the basement had multiple fire-rated doors that failed to positively latch in their frames. The facility was unable to provide a Life Safety Code floor plan of the area at the time of the survey to verify if the basement was considered one hazardous suite.

Interview with the maintenance supervisor on July 29, 2025, at 10:01 a.m., confirmed the deficiency.

Plan of Correction - To be completed: 09/12/2025

The facility has hired an architect to draw up accurate floor plans for the basement to include the following:

a. Smoke barrier walls (outside wall to outside wall and enclosures)

b. Fire barrier walls (indicating 1-2 hour walls)

c. Horizontal exits

d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan

e. Required exits should be clearly noted

f. Shaft walls

The doors will be addresses based on the above.

Initial comments:Name: ENTRANCE - Component: 03 - Tag: 0000

Facility ID #022102
Component 03
New Entrance

Based on a Medicare/Medicaid Recertification Survey completed on July 29, 2025, it was determined that Transitions Healthcare Autumn Grove Care Center was not in compliance with the requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected, wood frame building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Observations:
Name: ENTRANCE - Component: 03 - Tag: 0353

Based on document review, observation, and interview, the facility failed to meet sprinkler system maintenance and inspection requirements, affecting the entire facility.

Findings include:

Document review on July 29, 2025, at 8:55 a.m., revealed the internal tank inspection, completed October 23, 2024, listed the following deficiencies:

A. (8:55 a.m.) The interior coating system was 20 years old and showing major signs of failure, mainly in the 2nd and 3rd shell rings;

B. (8:55 a.m.) Interior drain line showed significant signs of coating failure.

Interview with the maintenance supervisor on July 29, 2025, at 8:55 a.m., confirmed the deficiencies at the time of the survey and stated a repair company was scheduled to fix the deficiencies.

Plan of Correction - To be completed: 08/26/2025

The repairs to the internal tank are scheduled to be completed by August 26, 2025

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