Transitions Healthcare Allens Cove

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF558Mar 19, 2026

  Based on facility policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five of 16 residents reviewed (Residents 10, 15, 26, 30, and 52). Findings include: Review of facility policy, titled Resident Rights last revised February 6, 2025, read, in part, The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. […]

• No harm, potential for more than minimal, patternF628Mar 19, 2026

  Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents received a transfer notice with the required included information upon transfer/discharge for two of three residents reviewed for hospitalizations (Residents 5 and 30). Findings include: Review of facility policy titled, Resident Discharge/Transfer from Facility, with an effective date of January 21, 2025, read, in part, Upon a transfer or discharge of a Resident, the facility must: Notify the Resident and the Resident representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to the resident/resident representative. […]

• No harm, potential for more than minimal, patternF947Mar 19, 2026

  Based on personnel training record review and staff interview, it was determined that the facility failed to ensure each nurse aide was provided required in-service training, consisting of no less than 12 hours per year, which included dementia management and resident abuse prevention for four of five nurse aide employee records reviewed (Employees 1, 2, 3, and 5). Findings Include: Review of personnel information revealed Employee 1's hire date was January 5, 2024; Employee 2's hire date was November 13, 2023; Employee 3's hire date was October 12, 2024; and Employee 5's hire date was March 3, 2025. Review of facility training records failed to reveal that the aforementioned Employees completed 12 hours of required annual training in the past 12 months. […]

• No harm, potential for more than minimal, patternF761Apr 23, 2025

  Based on facility policy review, observation, staff interview, and facility document review, it was determined that the facility failed to store medications under proper temperature controls in one of one medication rooms reviewed. Findings include: Review of facility policy, titled Storage of Medications with a last revised date of August 2020, and a last review date of May 2024, revealed the following: II. Temperature 1. All medications are maintained within the temperature ranges noticed in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC); c. Refrigerated: 36 F to 46 F (2 C to 8 C) with a thermometer to allow temperature monitoring; 2. […]

• No harm, potential for more than minimal, patternF812Apr 23, 2025

  Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen. Findings include: Review of facility policy, titled Food Storage last reviewed [DATE], read, in part, All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. All containers or storage bags must be legible and accurately labeled and dated. […]