Pennsylvania Department of Health
TRANSITIONS HEALTHCARE SHOOK HOME
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 59 surveys for this facility. Please select a date to view the survey results.

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TRANSITIONS HEALTHCARE SHOOK HOME - 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 April 15, 2025, at Transitions Healthcare Shook Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

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

Facility ID #100902
Component 01
Original Building

Based on a Medicare/Medicaid Recertification Survey completed on April 15, 2025, it was determined that Transitions Healthcare Shook Home it was determined there were no deficiencies identified under 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 three-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

Initial comments:Name: PERSONAL CARE BLDG - Component: 02 - Tag: 0000

Facility ID #100902
Component 02
Quarters Building

Based on a Medicare/Medicaid Recertification Survey completed on April 15, 2025, at Transitions Healthcare Shook Home, it was determined there were no deficiencies identified under 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 three-story, Type II (111), protected noncombustible structure, with a basement, which is fully sprinklered.

Plan of Correction:

Initial comments:Name: PT & NURSING ADDITION - Component: 03 - Tag: 0000

Facility ID #100902
Component 03
PT and Nursing Addition

Based on a Medicare/Medicaid Recertification Survey completed on April 15, 2025, it was determined that Transitions Healthcare Shook Home was not in compliance with the following requirements of the Life Safety Code for a new 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 three-story, Type II (111), protected noncombustible structure, without a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Stairways and Smokeproof Enclosures:

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.

Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with 7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Observations:
Name: PT & NURSING ADDITION - Component: 03 - Tag: 0225

Based on observation and interview, it was determined the facility failed to maintain stairtower doors to be within the allowed gap margins, on two of three floors within the component.

Findings include:

1. Observation on April 15, 2025, at 1:20 PM, revealed the 1st and 2nd floor Stairtower A doors had gaps greater than 1/8 inch.

Interview with Director of Maintenance on April 15, 2025, at 1:20 PM, confirmed the door exceeded the allowed gap margins.

Plan of Correction - To be completed: 06/14/2025

1st and 2nd Floor Stairtower A doors will be corrected to be within the allowed gap margins.

Maintenance Staff were educated on Stairways and Smokeproof Enclosures Stairways used as exits cannot have gaps greater than 1/8 gap.

Director of Plant Operations or designee will audit 1 time a month.

Audits will be reported at QAPI

NFPA 101 STANDARD Hazardous Areas - Enclosure:

Hazardous Areas - Enclosure
2012 New
Hazardous areas are protected in accordance with 18.3.2.1. The areas shall be enclosed with a 1-hour fire-rated barrier, with a 3/4-hour fire-rated door without windows (in accordance with 8.7.1.1). Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. Hazardous areas are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, and 8.4.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
18.3.2.1, 7.2.1.8, 8.4, 8.7, 9.7

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 and less than 100 square feet)
g. Combustible Storage Rooms/Spaces
(over 100 square feet)
h. Laboratories (if classified as Severe
Hazard - see K322)

Observations:
Name: PT & NURSING ADDITION - Component: 03 - Tag: 0321

Based on observation and interview, it was determined the facility failed to request a change of use for a hazardous area enclosures, affecting one of three floors within the component.

Findings include:

1. Observation on April 15, 2025, at 1:50 PM, revealed the ground floor Pool Area was being used for storage of multi-medical record boxes and red isolation containers.

Interview with the Director Maintenance on April 15, 2025, at 1:50 PM, confirmed the storage of hazardous items outside a 1-hour protected area.

Plan of Correction - To be completed: 05/20/2025

The medical records and red isolation containers in the ground floor pool area are being moved offsite.

Maintenance staff was educated on storing items in the building in 1 hour protected area only.

Director of Plant Operations or designee will audit 1-time a month unused rooms in the building to ensure items are stored within a 1 hour protected area.

Results will be reported at QAPI.

NFPA 101 STANDARD Soiled Linen and Trash Containers:

Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7

Observations:
Name: PT & NURSING ADDITION - Component: 03 - Tag: 0754

Based on observation and interview, it was determined the facility failed to provide a protected space for soiled-linen and trash containers exceeding 32 gallons, on one of three floor within the component.

Findings include:

1. Observation on April 15, 2025, at 1:35 PM, revealed three 96-gallon shredder containers were stored in the ground floor Lobby, which did not have a 1-hour protected rating.

Interview with the Director of Maintenance on April 15, 2025, at 1:35 PM, confirmed the shredder containers were not being stored in a rated assembly.

Plan of Correction - To be completed: 05/20/2025

The three 96-gallon shredder containers were moved to an area with 1 hour protected rating.

Maintenance staff was educated a 1-hour protected rating space is required for storage of soiled-linen and trash containers exceeding 32 gallons.

Director of Plant Operations or designee will audit 1 time a week for a month; if compliance is achieved; then random audits monthly of soled-linen and trash containers exceeding 32 gallons are stored in a 1-hour protected space.

Audit results will be reported at QAPI.

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