Pennsylvania Department of Health
TRANSITIONS HEALTHCARE WASHINGTON PA
Building 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

There are 38 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 WASHINGTON PA - 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 February 26, 2024, at Transitions Healthcare Washington, 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# 085702
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 26, 2024, it was determined that Transitions Healthcare Washington PA 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 III (200), unprotected ordinary building, with a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

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.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0131

Based on observation and interview, it was determined the facility failed to maintain the two-hour fire resistance rating that separate the Personal Care Building from the Skilled Nursing Building on the basement floor, affecting 2 of nine smoke compartments.

Findings include:

1. Observation on February 26, 2024, at 9:50 a.m., revealed the door on the basement floor, seperating the Personal Care Building from the Skilled Nursing Building, failed to fully close and latch in the frame.

Interview with the Facility Administrator and the Director of Plant Operations on February 26, 2024, at 12:30 p.m., confirmed the deficiencies with the doors in the two-hour fire rated occupancy separation wall.

Plan of Correction - To be completed: 03/20/2024

1.Facility maintenance department repaired and tightened hinges to ensure that the door closes and latches
2. No other doors were identified as not fully latching.
3. Education was provided to the maintenance department on auditing door closures.
4. An audit will be conducted monthly by the maintenance director or designee to ensure that all smoke doors latch properly, results will be taken the QAPI committee for review of findings and further interventions if warranted.
5. Date of compliance 3/20/2024

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on documentation review, observation, and interview, it was determined the facility failed to maintain the kitchen hoods in one instance, affecting one of nine smoke compartments.

Findings include:

1. Document review and observation on February 26, 2024 at 8:55 a.m., revealed the most recent semi-annual kitchen hood cleaning was completed on July 10, 2023, and the next cleaning was due by the end of January, 2024.

Interview with the Facility Administrator and the Director of Plant Operations on February 26, 2024, at 12:30 p.m., confirmed the facility lacked documentation for a second semi-annual hood cleaning.

Plan of Correction - To be completed: 03/20/2024

1. The facility notified the hood vendor who produced documentation that hood cleaning was completed on February 28, 2024

2. The dates of the semiannual cleaning are loaded in TELS system as a visual trigger to ensure that documentation is obtained semiannually.

3. An audit will be conducted semiannually by the safety committee to ensure that semiannual hood cleaning are completed timely

4. Audits will be taken to QAPI for review of findings and further interventions if warranted.

5. Date of compliance 3/20/2024

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

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.

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 observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting the entire facility.

Findings include:

1. Observation on February 26, 2024, revealed the following automatic sprinkler system deficiencies:

a) 8:55 a.m., review of documentation revealed the facility failed to provide documentation for the the required third quarter sprinkler system inspection;
b) 9:45 a.m., there were multiple gaps in the ceiling tile of the laundry room on the first floor.

Interview with the Facility Administrator and the Director of Plant Operations on February 26, 2024, at 12:30 p.m., confirmed the sprinkler deficiencies.

Plan of Correction - To be completed: 03/20/2024

1. Facility contacted vendor and obtained proof of the 3rd quarter sprinkler system inspection. This was completed, September 21, 2023.

2. All other documents were present during inspection.

3. The dates of the quarterly sprinkler system inspections are loaded in TELS as a visual trigger to ensure that documentation is obtained quarterly from vendor.

4. An audit will be conducted quarterly and taken to the QAPI meeting for review of findings and further interventions is warranted.

5. Date of compliance 3/20/2024

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