Transitions Healthcare Shook Home

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 16 residents reviewed (Resident 11).

Inspectors wroteBased on facility policy review, observations, facility documentation review, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen, in two of two kitchenettes, and a resident unit refrigerator (second floor upper-level unit).

Inspectors wroteBased on facility policy review, facility document review, observations, and resident and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for one of 16 residents reviewed (Resident 56).

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to implement a comprehensive person-centered care plan to meet a resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for one of 16 residents reviewed (Resident 3).

Inspectors wroteBased on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for three of 19 residents reviewed (Residents 4, 56, and 60).

Inspectors wroteBased on observations, facility policy, and staff interviews, it was determined that the facility failed to discard expired medications for one of one medication storage rooms observed (2nd floor), and failed to place opened dates on medications in one of two medication carts (2nd floor) and one of one medication storage rooms (2nd floor) observed. Findings Include: Review of facility policy, titled Storage of Medications, last revised April 7, 2025, read, in part, III. Expiration Dating (Beyond-Use Dating) 3. Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmics, nitroglycerin tablets, and blood sugar testing solutions and strips require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency. [...]

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure staff implement infection control policies to prevent the spread of infection for one of 19 residents observed on contact precautions (Resident 5). Findings Include: Review of facility policy, titled IC-Enhanced Barrier Precautions, revised April 1, 2024, revealed, Enhanced barrier precautions apply when: A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; and contact precautions do not otherwise apply. [...]

Inspectors wroteBased on clinical record review, policy review, other resources, and staff interviews, it was determined that the facility antibiotic stewardship program allows for lapsed doses of antibiotic usage as determined by one of 19 residents reviewed (Resident 60). Findings Include: Review of the facility policy, titled Antibiotic Stewardship- Order for Antibiotics, reviewed April 7, 2025, When a culture and sensitivity (C&S) is ordered, it will be completed, and; lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. [...]

Inspectors wroteBased on facility policy review, clinical record review, hospital record review, facility investigation report, facility provided documents, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to prevent a significant medication error, which resulted in actual harm as evidenced by a hospital transfer for low blood pressure, low heart rate and altered consciousness for one of three residents reviewed (Resident 1).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to post the most recent Federal or State survey results for one of one survey books observed (located in main entrance lobby). Findings Include: Observation of the survey binder located in the main entrance lobby on April 1, 2025, at 11:27 AM, revealed the most recent survey results present were dated August 2023. Review of the facility's survey history revealed the most recent survey result that could have been posted was conducted on March 19, 2025. During an interview with the Nursing Home Administrator on April 2, 2025, at 1:02 PM, he revealed the expectation that the survey books should be up to date and confirmed that they had been updated. 28 Pa.

Inspectors wroteBased on clinical record review, facility document review, and staff interviews, it was determined that the facility failed to provide a notice of transfer that included the required information for three of four resident records reviewed for hospitalizations (Residents 47, 50, and 58).

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to monitor hydration to ensure proper hydration for one of two residents reviewed for hydration (Resident 50).

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to ensure food was prepared and served under sanitary conditions in two of two dining rooms observed (1st and 2nd floor).

Inspectors wroteBased on review of facility policy, review of select facility documentation, and staff interview, it was determined that the facility failed to ensure all alleged violations involving abuse were reported immediately for one of two residents reviewed for abuse (Resident 52).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for two of 17 residents reviewed (Residents 13 and 24).

Inspectors wroteBased on facility policy review, review of facility admission agreement, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the resident care plan was reviewed and revised to reflect the resident's current status for two of 21 residents reviewed (Residents 48 and 55).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards of practice to ensure each resident's highest level of well-being for one of three residents reviewed for advanced directives (Resident 51). Findings Include: Review of Resident 51's clinical record revealed diagnoses that included Alzheimer's disease (gradually progressive brain disorder that causes problems with memory, thinking, and behavior) and type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar [glucose] as a fuel, resulting in too much sugar circulating in the bloodstream). [...]

Inspectors wroteBased on review of facility policy, record review, observation, and staff interview, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers for one of one resident reviewed (Resident 49). Findings Include: Review of facility policy, titled CLIN-046 Dressing Changes, Revised March 28, 2016, revealed in step 11. Write the date, time, and initials on the dressing. Review of facility policy, titled IC- Enhanced Barrier Precautions, with a revision date of April 1, 2024, indicated that residents on enhanced barrier precautions require the use of gloves and a protective gown for high contact resident care activities, including wound care and any skin opening requiring a dressing. [...]

Inspectors wroteBased on review of facility policy, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of three residents reviewed for respiratory care (Resident 50).

Inspectors wroteBased on policy review, clinical record review, and staff interview, it was determined that the facility failed to adequately monitor psychotropic medications to ensure that residents were free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 24).

Inspectors wroteBased on observation, clinical record review, review of select facility documents, and staff interviews, it was determined that the facility failed to ensure that residents were served food that accommodated their allergies and intolerances for one of 17 residents reviewed (Resident 32).

Inspectors wroteBased on observation, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and to promote dignity related to use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for one of three residents reviewed for catheter use (Resident 1). Findings Include: Review of facility policy, titled Catheter Care - Routine, revised March 21, 2016, revealed, Provide privacy cover for drainage bag as needed. Review of facility policy, titled, Catheterization - Foley, revised January 23, 2017, revealed, Keep the catheter bag below the level of the bladder at all times. Do not rest the bag on the floor. [...]

Inspectors wroteBased on facility policy review, clinical record review, hospital record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided after a change in condition for one of 16 residents reviewed (Resident 1). This failure resulted in continued decline, which required hospitalization for hypovolemic shock (emergency condition in which severe blood or other fluid loss makes the heart unable to pump enough blood to the body), low blood pressure, and cardiac arrest for Resident 1. This failure placed an additional six out of six residents reviewed who were identified as having a change in condition in an immediate jeopardy situation (Residents 9, 12, 13, 14, 15, and 16). The facility also failed to monitor blood glucose levels for residents with Diabetes Mellitus for two of 16 residents reviewed (Resident 1 and 9).

Inspectors wroteBased on facility policy review, clinical record review, hospital record review, and resident representative and staff interviews, it was determined that the facility failed to notify the physician after a change in a resident's condition and failed to notify a resident's representative of a change in treatment for one of four residents reviewed (Resident 1). Immediate Jeopardy was identified because the failure to notify the physician resulted in a lack of physician oversight. This caused a delay in treatment, which resulted in transfer to the hospital for hypovolemic shock (emergency condition in which severe blood or other fluid loss makes the heart unable to pump enough blood to the body), hypotension (low blood pressure), hyperglycemia (elevated blood sugar), and cardiac arrest for Resident 1.

Inspectors wroteBased on facility policy reviews, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the resident care plan was reviewed and revised to reflect the resident's current status for four of 15 residents reviewed (Residents 18, 27, 41, and 45).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 15 residents reviewed (Residents 7, 27, and 41). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included muscle weakness and other abnormalities of gait and mobility (difficulty walking caused by various conditions). Review of facility incident reports dated March 11 and 12, 2024, revealed that Resident 7 experienced a fall on each of those dates when she was lowered to the floor by staff. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for three of 15 residents reviewed (Residents 7, 41, and 154). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). [...]

Inspectors wroteBased on clinical record review, observations, and staff interviews, it was determined that the facility failed to provide care and services to prevent and treat pressure injuries in accordance with professional standards for one of three residents reviewed for pressure injuries (Resident 9).

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for two of 18 residents reviewed (Residents 7 and 154). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included anxiety disorder (mental disorder characterized by feelings of worry about future events and/or fear in reaction to current events) and major depressive disorder (mental disorder characterized by at least two weeks of low mood that is present across most situations). [...]

Inspectors wroteBased on clinical record review, policy review, and staff interviews, it was determined that the facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, that irregularities were reported to the appropriate parties, and that these reports were acted upon for two of 5 residents reviewed for unnecessary medications (Residents 7 and 41).