Transitions Healthcare Shook Home
TRANSITIONS HEALTHCARE SHOOK HOME in CHAMBERSBURG, PA — inspection on March 5, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of facility provided information from their employee handbook, dated November 1, 2203, revealed, in part, F.
Dress Code Policy: Since the appearance of the staff is a reflection of the employee, the resident, and the Company, the dress code provides for a consistent professional appearance in the dress of the staff.
Should an employee report to work improperly dressed or groomed, his/her supervisor may instruct the employee to return home to change.
Employees will not be permitted to work when they are improperly dressed.
For all employees in all departments: No sweatpants; blouses are to be non-revealing in cut. In addition, the dress coded indicated for nursing department personnel was noted to be a uniform or scrub suit and that the Charge Nurse, Nurse Supervisor, or Director of Nursing may determine the appropriateness of the uniform and has the right to verbally warn the employee or send the employee off duty to change the uniform.
Observation on the second-floor nursing unit on March 2, 2026, at 10:50 AM, Employee 2 (Licensed Practical Nurse) was observed to be dressed in sweatpants with Hello Kitty appliques noted on the leg and a short, blue and white striped shirt.
Employee 2's abdomen was noted to be exposed. In addition, Employee 2 was not wearing a name tag.
During an immediate interview with Employee 2, she confirmed her identity, job role, and indicated that she was aware that she was to wear a nametag.
She said it was possibly in her purse or on her jacket.
During a resident interview with Resident 56 in her room on March 2, 2026, at 1:10 PM, Employee 2 entered the room without knocking on the door.
She was still dressed in sweatpants and the short shirt that exposed her abdomen, and she had no name tag.
She did not identify herself to Resident 56.
Employee 2 stated, I have your medications.
During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 4, 2026, at 1:34 PM, the DON acknowledged that Employee 2 was not appropriately dressed and indicated that Employee 2 was a new employee and new nurse who cannot afford scrubs.
The DON further indicated that she has now instructed Employee 2 to wear her school scrubs until she can afford to purchase her own scrubs.
The NHA confirmed that he would expect staff to wear proper identification and to properly identify themselves prior to entering a resident's room. He further indicated that Employee 2 was provided with a name tag. 28 Pa Code 201.14(a) Responsibility of licensee.28 Pa Code 201.18(b)(3) Management.28 Pa Code 201.29(a) Resident rights.28 Pa Code 211.11(d)(1)(2) Nursing services.
395918 03/05/2026
Transitions Healthcare Shook Home 55 South Second Street Chambersburg, PA 17201
Review of Resident 3's clinical record revealed diagnoses that included muscle weakness and depression.
During a resident interview with Resident 3 on March 2, 2026, at 1:40 PM, he indicated that he does not get showers very often and described them as few and far between.
Review of Resident 3's care plan revealed his bathing preference was to receive a shower once a week, dated January 14, 2024.
Review of Resident 3's shower/bath documentation from February 3, 2026 -March 4, 2026, revealed that he was documented as receiving a shower once on February 15, 2026, and received a bed bath all other times.
During a staff interview with the Director of Nursing (DON) on March 5, 2026, at 10:20 AM, she indicated that he does occasionally refuse a shower.
She said Resident 3's autonomy of care is presumed because of his high level of cognition and that he could voice his concerns or requests to staff when care is being provided.
The DON confirmed that Resident 3's preferences should have been care planned so all staff providing care could be aware and make efforts to accommodate them. 28 Pa.
Code 201.24(e)(4) admission policy.28 Pa.
Code 211.12(d)(2)(3)(5) Nursing services.
395918 03/05/2026
Transitions Healthcare Shook Home 55 South Second Street Chambersburg, PA 17201
Review of Resident 4's clinical record revealed that he was treated for the flu from January 30, 2026 -February 6, 2026.
Review of Resident 4's care plan revealed an active care plan focus for influenza, dated January 30, 2026.
During a staff interview with the Director of Nursing on March 5, 2026, at 10:20 AM, she confirmed that Resident 4's influenza was resolved in early February 2026, and that his care plan should have been revised at that time.
Review of Resident 56's clinical record revealed diagnoses that included vascular dementia (brain damage caused by multiple strokes, which causes memory loss in older adults) and hearing loss.
Review of Resident 56's clinical record revealed that she was treated for a urinary tract infection (UTI) from February 1-4, 2026.
Review of Resident 56's care plan revealed an active care plan focus for a UTI, dated February 1, 2026.
During a staff interview with the Nursing Home Administrator (NHA) on March 5, 2026, at 11:26 AM, the NHA indicated that the care plan should have been revised when the UTI resolved and that Resident 56's care plan has now been revised.
Review of the clinical record for Resident 60 revealed diagnoses that included Parkinson's disease with dyskinesia (uncontrolled, involuntary movement) and retention of urine (inability to fully empty the bladder).
Review of the clinical record for Resident 60 revealed resident had a UTI on November 1, 2025, that was resolved with treatment.
Review of Resident 60's care plan on February 4, 2026, revealed the UTI that occurred November 1, 2025, was still present on the care plan.
During an interview with the NHA on February 5, 2026, at 10:45 AM, he agreed that care plans should reflect the Resident's status. 28 Pa.
Code 211.12(d)(1)(2)(3)(5) Nursing services.
395918 03/05/2026
Transitions Healthcare Shook Home 55 South Second Street Chambersburg, PA 17201
Review of Resident 11's current physician orders revealed an order for losartan potassium 50 milligram tablet give one tablet by mouth one time a day hold for systolic blood pressure less than 100 or blood pressure less than 100/60, dated October 15, 2025.
Review of Resident 11's Medication Administration Records from October 15, 2025, through March 4, 2026, revealed the following:1) There was no documentation of Resident 11's blood pressure documented with each medication administration.2) The losartan was coded as 5=Hold See Progress Notes on November 2 and 7, 2025, and December 14, 2025.
All other doses between October 15, 2025, and March 4, 2026, were documented as being administered.
Review of Resident 11's clinical record progress notes revealed the following:1) November 2, 2025, at 10:26 AM, losartan was held due to a pulse of 56 (which was not one of the physician's provided parameters for holding the medication);2) November 7, 2025, at 9:35 AM, losartan was held due to a pulse of 56 (which was not one of the physician's provided parameters for holding the medication); and3) December 14, 2025, at 8:52 AM, losartan was held due to a blood pressure of 99/54.
Review of Resident 11's blood pressure documentation in the vitals tab of the clinical record revealed that Resident 11's blood pressure was documented on six occasions that could possibly coincide with the losartan medication administration (October 16, 17, and 18, 2025; December 3, 2025; January 8, 2026; and February 9, 2026).
Review of the Resident 11's clinical record revealed no evidence of blood pressures being taken consistently, prior to administration of medication with parameters.
During a staff interview with the Nursing Home Administrator and the Director of Nursing (DON) on March 5, 2026, at 2:04 PM, the DON indicated that she could not say whether nurses consistently took Resident 11's blood pressure prior to administering the losartan.
She said that the nurses may have just taken the blood pressure and wrote it on their report sheet instead of documenting it in the clinical record.
She confirmed that there should have been a corresponding box with the medication administration for nurses to document Resident 11's blood pressure to reflect that the physician's ordered parameters were followed. 28 Pa.
Code 201.18(b)(1) Management.28 Pa.
Code 211.9(a)(1) Pharmacy services.28 Pa.
Code 211.12(d)(1)(5) Nursing services.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
395918 03/05/2026
Transitions Healthcare Shook Home 55 South Second Street Chambersburg, PA 17201
Based on observations, facility policy, and staff interviews, it was determined that the facility failed
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.
Observation of the second floor medication storage room on March 4, 2026 at 10:00 AM, revealed one open multidose vial of tuberculin solution with no open date label.
Further observation of the second floor medication storage room on March 4, 2026 at 10:00 AM, revealed one box of 25 gauge needles with an expiration date of February 28, 2026, and one open vial of insulin lispro labeled with an open date of January 17, 2026. An interview with Employee 1 on March 4, 2026, at 10:00 AM, revealed that the tuberculin solution should be labeled with an open date when opened and expired medication and supplies should be discarded.
Observation of the second floor medication cart on March 5, 2026 at 11:15 AM, revealed one open bottle of liquacel with no open date label and one open Lantus insulin pen with no open date label. An interview with Employee 1 on March 5, 2026 at 11:15 AM, revealed that liquacel bottles and insulin pens should be labeled with an open date when opened due to a shortened expiration date once opened.
During an interview on March 5, 2026, at 1:08 PM, with the Nursing Home Administrator and Director of Nursing, revealed that it was the facility's expectation that medications be labeled with open dates when opened and expired medications and supplies be disposed of. 28 Pa.
Code 201.18(b)(1) Management28 Pa.
Code 211.9(a)(1) Pharmacy services
395918 03/05/2026
Transitions Healthcare Shook Home 55 South Second Street Chambersburg, PA 17201
Review of food temperature logs from February 22-28, 2026, and March 1-3, 2026, revealed that staff do not consistently check the temperature of cold food items or beverages at point of service.
During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on March 4, 2026, at 1:29 PM, the NHA confirmed that he would expect foods to be labeled/stored properly, dishes to be stored properly, and that food temperatures would be checked according to policy. He also confirmed that he would expect staff to wear gloves when preparing food. 28 Pa.
Code 201.18(b)(1)(3) Management.28 Pa.
Code 211.6(f) Dietary services.
395918 03/05/2026
Transitions Healthcare Shook Home 55 South Second Street Chambersburg, PA 17201
Review of facility policy, titled IC-Enhanced Barrier Precautions, revised April 1, 2024, revealed, 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.
Review of Resident 5's clinical record revealed diagnoses that included pressure ulcer of sacral region, stage 3 (a severe, full-thickness wound where the true depth [Stage III or IV]) and diabetes (a chronic condition when the body cannot properly control blood glucose levels). [[NAME]] I feel the ulcer piece isn't finished Observation of Resident 5's room door on March 2, 2025, at 10:30 AM, failed to reveal any signage that Resident 5 was on enhanced barrier precautions or that it was necessary to use personal protective equipment when caring for Resident 5.
Observation of Resident 5's room door on March 3, 2025, at 11:30 AM, failed to reveal any signage that Resident 5 was on enhanced barrier precautions or that it was necessary to use personal protective equipment when caring for Resident 5.
Observation of Resident 5's stage 3 pressure ulcer treatment on March 5, 2026, at 9:45 AM, revealed that Resident 5 had a stage 3 pressure ulcer on her sacrum that is healing but still an opening in her skin.
Review of Resident 5's wound team consult dated March 2, 2026, at 11:55 PM, revealed that Resident 5 had a stage 3 pressure ulcer on her sacrum.
Review of Resident 5's physician orders failed to reveal a physician's order for Resident 5 to be on enhanced barrier precautions.
Review of Resident 5's care plan failed to reveal any care plan dealing with Resident 5's need to be on enhanced barrier precautions.
Interview with the Director of Nursing on March 3, 2026, at 12:15 PM, revealed that she was under the impression that Resident 5's pressure ulcer had closed and that enhanced barrier precautions were no longer needed. 28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services
395918 03/05/2026
Transitions Healthcare Shook Home 55 South Second Street Chambersburg, PA 17201
therapy should be started, continued, modified, or discontinued.
Based on National Institute of Health Resource, dated December 11, 2025, lapsed or missed doses particularly early in treatment are critical issues that reduce treatment efficacy, allow for the development of drug resistance, and may necessitate dose increases or adjustments.
Based on current Food and Drug Administration recommendations the treatment for Proteus mirabilis (Gram negative rod bacteria capable of causing symptomatic infections including cystitis [inflammation of the bladder] and pyelonephritis [kidney infection] and is present in cases of asymptomatic bacteriuria, particularly in the elderly), complicated urinary tract infections, the dosage should be 500 milligrams twice a day for 7 days.
Review of the clinical record for Resident 60 revealed diagnoses that included Parkinson's disease with dyskinesia (involuntary, erratic movements) and retention of urine (inability to empty the bladder completely).
Further review of the clinical record for Resident 60 revealed a diagnosis of urinary tract infection (UTI) was confirmed by a laboratory culture on November 28, 2026.
The microbiology results revealed > (greater than) 100,000 CFU/ml (colony-forming units per milliliter) Proteus mirabilis (Abnormal). On November 28, 2025, at 3:25 PM, the provider ordered Cipro (ciprofloxacin - a potent antibiotic used to treat serious bacterial infections, including urinary tract infections) 250 milligrams by mouth twice a day for 3 days.
The antibiotic started on November 28, 2025, at 6:00 PM. Resident 60 received additional doses on November 29, 2025, at 6:00 AM and 6:00 PM; November 30, 2025, at 6:00 AM and 6:00 PM; and was stopped on December 1, 2025, at 6:00 AM.
The Provider's designated Registered Nurse visited Resident 60 and reported the Resident was without any UTI symptoms and the antibiotic was discontinued as ordered initially. Resident 60 received a follow-up visit on December 3, 2025, and during the physical assessment Resident had suprapubic tenderness (pain or sensitivity in the lower abdomen just above the pubic bone) often signaling underlying bladder or pelvic issues like urinary tract infections or cystitis. On December 3, 2025, the provider wrote new orders for Cipro 500 mg twice a day (1000 mg daily) for 7 days due to continued symptoms related to a complicated UTI.
During an interview with Employee 9 (ICP-Infection Control Preventionist) on March 5, 2026, at 10:00 AM, Employee 9 stated that residents under the care of this Resident's provider are usually treated for 3 days with antibiotics when diagnosed with UTI with a positive culture.
The Resident is evaluated by a Registered Nurse for symptoms and, if there are no symptoms, the antibiotic ends as scheduled.
When the Provider reevaluates at the next visit if there are symptoms, the antibiotic is restarted.
During an interview with the Nursing Home Administrator (NHA) on March 5, 2026, at 10:45 AM, the NHA stated that antibiotic usage is referred to the provider. 28 Pa.
Code 201.14(a) Responsibility of licensee28 Pa.
Code 201.18(b)(1)(3) Management28 Pa.
Code 211.12(c)(d)(3) Nursing services