Transitions Healthcare Shook Home

In the surveyor’s words

From the most serious findings on record at Transitions Healthcare Shook Home, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Sep 29, 2021

  Based on review of facility documentation, facility policy review and staff interviews, it was determined that the facility failed to establish/implement a staff screening procedure to identify staff who have signs/symptoms of COVID-19 and did not prohibit a symptomatic staff member who had COVID-19 from providing direct care to residents, which exposed residents to the COVID-19 virus, resulting in an immediate jeopardy. Findings include: During an interview with the Nursing Home Administrator (NHA) on September 28, 2021, at 10:55 AM he confirmed he did not have a policy that addressed the COVID-19 screening process and what to do if a staff reported to work with positive symptoms. He stated that they follow the PA-HAN 553. […]

• Immediate jeopardy, patternF684Jun 20, 2024

  Based 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). […]

• Immediate jeopardy, isolatedF580Jun 20, 2024

  Based 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. […]

• Actual harm, isolatedF760Jul 22, 2025

  Based 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).Findings include: Review of facility policy, titled CLIN-080 Medication Pass, revealed the following, in part, 2. The MAR [Medication Administration Record] is reviewed for the right resident, right drug, right time, right route, and right dose. 3. […]

• Actual harm, isolatedF600Jan 15, 2022

  Based on clinical record review, review of select facility documentation, policy review, and staff interviews, it was determined that the facility failed to prevent neglect for one of seven residents reviewed (Resident 1) resulting in a change in mental status due to head injury requiring hospitalization . Findings include: A review of the facility's policy title, Resident Abuse, Neglect, & Exploitation Prevention Policy, last revised 12/2017, states the definition of neglect, the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. […]