Allied Services Transitional Rehab Unit

In the surveyor’s words

From the most serious findings on record at Allied Services Transitional Rehab Unit, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 7, 2023

  Based on observations, review of clinical records, select facility policies, and information submitted by the facility and staff interviews, it was determined that the facility failed to provide adequate staff supervision of a resident to monitor the resident's whereabouts and timely identify the resident's absence from the facility to assure prompt implementation of established procedures for a missing resident, which placed the resident in immediate jeopardy to her health and safety for one resident out of 12 residents sampled (Resident 18). […]

• Actual harm, isolatedF689Apr 6, 2022

  Based on a review of clinical records and select incident reports, and staff interview it was determined that the facility failed to provide necessary staff supervision based on the resident's individual known risk factors, history of falls and displays of unsafe behaviors to prevent a fall resulting in serious injury, a fractured femur, for one of six residents reviewed (Resident CR2). Findings include: A review of clinical record revealed that Resident CR2 was admitted to the facility on [DATE], with diagnoses, which included dementia, heart failure, and history of falls. […]

• No harm, potential for more than minimal, patternF761May 3, 2024

  Based on observation and staff interview, it was determined that the facility failed to ensure proper storage and adherence to expiration/use by dates for pharmaceutical products in one of one medication rooms observed. Findings include: Observations of the facility's medication room on [DATE], at approximately 10:35 AM revealed 38 Max Zero Needless connectors that expired May, 8, 2023, 11 Max Zero Needless connectors that expired [DATE], one 20 gauge needle safety infusion set that expired [DATE], two 20 gauge needle safety infusion sets that expired [DATE], two 22 gauge Autoguard BC winged IV catheters that expired [DATE], one 24 gauge Autoguard BC winged IV catheter that expired February 8, 2023, two 27 gauge disposable needles that expired [DATE], two 27 gauge disposable needles that… […]

• No harm, potential for more than minimal, patternF697Aug 4, 2022

  Based on clinical record and select facility policy review and staff interview, it was determined that the facility repeatedly failed to ensure that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A review of facility policy entitled Pain Management Process last reviewed by the facility July 13, 2022, revealed that the license nurse is responsible for the accurate assessment of the resident's pain, initiating the appropriate non-pharmacological and pharmacological pain interventions, evaluating the outcome, and assuring all documentation that is required is met. […]

• No harm, potential for more than minimal, isolatedF655Dec 11, 2025

  Based on review of clinical records, review of facility documentation, and staff interviews, it was determined that the facility failed to develop and implement a baseline person-centered care plan within 48 hours of admission that addressed immediate clinical needs for one of one resident reviewed (Resident 52).Findings include:A review of the facility provided policy entitled Resident Comprehensive Care Plan last reviewed by the facility on October 25, 2025, indicated the facility will develop a comprehensive care plan, initiated on admission and reviewed after completion of each comprehensive assessment and quarterly assessment for each resident that includes measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs. […]