Pennsylvania Department of Health
TRANSITIONS HEALTHCARE WASHINGTON PA
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TRANSITIONS HEALTHCARE WASHINGTON PA
Inspection Results For:

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TRANSITIONS HEALTHCARE WASHINGTON PA - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a complaint, and an incident completed on August 29, 2025, it was determined that Transitions Healthcare Washington was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance.

Findings include:

Review of the facility policy "Transfer/Lift Policy," dated 1/6/25, indicated it is the facility's policy to provide safe care for each resident and staff when having to physically transfer/lift a resident and all resident care will be provided in accordance with the individual resident's care plan.

Review of the clinical record indicated Resident R1 was re-admitted to the facility on 6/21/24.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/26/25, included diagnoses of anxiety, spinal stenosis(spaces inside the spine get too small), muscle weakness, and syncope (sudden temporary loss of consciousness) with collapse. Review of Section GG: Functional Abilities indicated that Resident R1 required "substantial/maximal assistance" for chair/bed-to-chair transfers.

Review of a physician order dated 10/14/24, indicated Resident R1 transfer with a mechanical lift with the assist of two. This is the current order.

Review of Resident R1's plan of care for "ADLs (activities of daily living) Functional Status / Rehabilitation Potential," updated 10/14/24, indicated that the resident will transfer with a mechanical lift with the assist of two.

Review of a progress note dated 8/9/25, at 12:33 p.m. indicated, "Patient was being transferred from the bed to the wheelchair with assist x 1 when she struck her left shin on the wheelchair leg rest attachment causing a 5cm laceration to her anterior shin.

Review of a progress note dated 8/9/25, at 2:22 p.m. indicated, Patient returned from hospital with 2 internal sutured and 12 external sutures that will need removed here in 10 days.

Review of facility submitted information on 8/10/25, indicated On 8/9/25 at approximately 12:30 pm, resident was being transferred to her wheelchair by 1 CNA [certified nursing assistant] from the bed to the chair. Residents transfer statues is an assist times two with a hoyer. During this transfer the resident obtained a 5 cm laceration to her left anterior shin. Resident was sent to the emergency department for repair of the laceration and returned to the facility.

Review of an employee statement written by nursing assistant (NA), Employee E1, dated 8/10/25, indicated, "I was transferring her from the bed to the wheelchair when her left shin hit the bottom of the wheelchair. I noticed it was bleeding and went to get help from the licensed practical nurse (LPN) and registered nurse (RN) Supervisor. I did it by myself because the resident said one person can put her in the chair. I was not aware that she was a hoyer lift.

Review of the facility's plan of correction included:

-Wound will be monitored for signs/symptoms of infection.

-Nursing care plan updated to include any new orders.

-Interventions are put into place to prevent injuries or reduce the risk of injuries for individual resident needs.

-PT/OT (physical therapy / occupational therapy) consult ordered for transfers.

-All residents are assessed on admission, quarterly and upon incident for appropriate care plan adjustments.

-All incidents and accidents are tracked and trended by the quality assurance committee and reviewed for recommendations to prevent injuries.

-Education provided to NA, LPN, and RN regarding how to look up residents transfer status, proper transfer protocol, and what to do if resident refuses assist of 2 with any type of lift.
During an interview on 8/28/25, NA employees E2, E3, E4, E5, E6, and E7 were interviewed, and confirmed they were provided education on resident transfer status, proper transfer protocol, and what to do if a resident refuses assist of 2 with any type of lift.

Review of education sign-in sheets on 8/28/25, confirmed in-service on transfer/lift protocol was completed on 8/11/25

During an interview on 8/28/25 at approximately 1:32 p.m., the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide adequate supervision to prevent injury that resulted in the actual harm of a laceration that required sutures for one of three residents (Resident R1). This was identified as past non-compliance.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(e)(1) Management.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 211.10(c)(d) Resident care policies.

28 Pa Code 211.12(d)(1)(2)(5) Nursing services.

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

Past noncompliance: no plan of correction required.

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