Transitions Healthcare Washington PA

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 29, 2022

  Based on facility policy review, clinical record review, facility specific documents, and staff interview, it was determined that the facility failed to provide adequate supervision and effective safety measures for one of twenty-one residents which resulted in actual harm during an elopement from the facility requiring emergency treatment and admission to hospital. Resident R18 eloped and was missing for approximately two hours and fifteen minutes before staff found her, which created actual harm requiring hospitalization . […]

• Actual harm, isolatedF600Jun 22, 2026

  Based on review of facility policy, published documents, clinical record review and staff interviews, it was determined that the facility failed to protect residents from neglect that resulted in actual harm of an impacted fracture of the right femur (thigh bone) for one of four residents (Resident R1). Findings include: Review of the facility policy dated 1/6/26, Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary. Review of the clinical record indicated Resident R1 was re-admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Jun 22, 2026

  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 an impacted right femur fracture (thigh bone) for one of four residents (Resident R1). Findings include: Review of the facility policy Transfer/Lift Policy, dated 1/6/26, 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 [DATE]. […]

• Actual harm, isolatedF689Aug 28, 2025

  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 [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Mar 16, 2023

  Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility. Findings include: A review of facility Cleaning and Sanitation of Dining and Food Service Areas policy dated 1/10/23, indicated that staff will maintain the cleanliness and sanitation of the dining and food service areas. During an observation made in the designated main kitchen on 3/32/23, at 9:45 a.m., ice machine had pink and black build-up substance inside. During an observation made in the designated main kitchen on 3/13/23, at 10:00 a.m. […]