Transitions Healthcare Allens Cove

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medications for one of five residents reviewed for unnecessary medications (Resident 8). Findings Include: Review of facility policy, titled Use of Psychotropic medications, with a revision date of January 21, 2025, revealed It is the policy of the Facility to assess the interventional necessity of psychotropic medication prior to delivery when related to the escalation of Resident behaviors Attempt to meet needs by the care plan and/or the behavior modification program, if appropriate. Use calm, friendly approach and try to redirect thoughts. Attempt to reassure and console. Document behavior, interventions tried and effectiveness on the 'Behavioral/Interventions' Sheet. [...]

Inspectors wroteBased on facility policy review, clinical record review, select facility investigative documentation, and staff interviews, it was determined that the facility failed to have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one of two residents reviewed for abuse (Resident 9).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to develop and implement a baseline person-centered care plan within 48 hours of a resident's admission to include the minimum healthcare information necessary to properly care for a resident and failed to provide the resident and their representative with a summary of the baseline care plan for two of 19 residents reviewed (Residents 4 and 68).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed ensure that resident and resident representative were involved in developing the comprehensive care plan and making decisions about his or her care for one of 19 residents reviewed (Resident 68).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 19 residents reviewed (Resident 48). Findings Include: Review of Resident 48's clinical record revealed diagnoses that included colon cancer and bladder cancer. Review of Resident 48's physician progress note dated March 13, 2026, revealed Resident 48 was being seen due to excessive blood draining into Resident's urostomy bag (a surgically created opening in the abdominal wall that allows urine to bypass a diseased or dysfunctional bladder. It is commonly used when the bladder is removed due to cancer, birth defects, or nerve damage, allowing urine to flow continuously into an external pouching system). [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for one of three residents reviewed for hospitalization (Resident 45). Findings Include: Review of facility policy, titled Bed Holds and Returns and Therapeutic Leave of Absence, last dated January 3, 2024, revealed The Facility is required to provide a bed hold under certain circumstances and make the Resident aware of the Facility's bed hold and return policy as related to hospitalization and therapeutic leave. The facility will provide information on bed hold requirements to all residents upon admission and again at time of transfer from the Facility. [...]

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 19 residents reviewed (Residents 9 and 32). Findings Include: Review of Resident 9's clinical record revealed diagnoses that included Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of nerves; can cause numbness, weakness, trouble walking, vision changes, and other symptoms) and neurogenic bladder (bladder dysfunction caused by nervous system conditions). Review of Resident 9's physician orders revealed an order dated June 28, 2024, for a Foley catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine; also known as an indwelling catheter). [...]

Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one of two residents reviewed for ADLs (Resident 23). Findings Include: Review of the facility policy, titled Activities of Daily Living last reviewed May 31, 2024, read, in part, Residents will gain and/or maintain as much independence as possible in ADLs which are essential to the individual's lifestyle. This refers to activities an individual performs on a regular basis, such as eating, dressing, hygiene (make-up, shaving, washing), transfers, reading, writing, housework, smoking, walking, and even driving. [...]

Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of one of 16 residents reviewed (Resident 24).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to provide restorative nursing care for range of motion exercises for one of three residents reviewed for position and mobility (Resident 29).

Inspectors wroteBased on review of facility policies, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications for three of three residents observed (Residents 9, 27, and 155).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and home-like environment in common areas and one of three resident rooms observed (South and East Hallways, Nurses Station, and Resident 1's room).

Inspectors wroteBased on employee handbook review, review of select facility documentation, and staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for three of five nurse aides reviewed (Employees 2, 3, and 4).

Inspectors wroteBased on observations, facility policy review, and staff interviews, it was determined that the facility failed to prepare and store food and equipment in accordance with professional standards for food service safety in the main kitchen area. Findings Include: Review of facility policy, titled Food Storage, dated 2021, revealed All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Review of facility policy, titled General Food Preparation and Handling, dated 2021, revealed The kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to provide notice of transfer to the Office of the State Long-Term Care Ombudsman, after a transfer out of the facility, for four of four residents reviewed for hospitalization (Residents 10, 14, 26 and 57).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure one of two residents reviewed for activities of daily living was provided care and services in regard to hygiene and bathing (Resident 32).

Inspectors wroteBased on resident interviews, staff interviews, and facility document review, it was determined that the facility failed to provide an ongoing activities program designed to meet the physical, mental and psychosocial well-being for five out of five residents who attended group for Resident Council (Resident 2, 13, 39, 51, and 260).

Inspectors wroteBased on review of the dietary extension sheets (guidelines as to what foods should or should not be served for specific therapeutic diets), the Diet Type facility report and staff interview it was determined that the facility failed to provide a therapeutic diet per physician's order, for four residents on a Renal/ low potassium diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balance in the body in individuals who's kidneys don't function as they should or who receive treatments to remove excess water, solutes and toxins from the blood due to kidney failure) and 18 residents on a Consistent Carbohydrate diet (CCD- meals are planned to provide a consistent amount of carbohydrates day to day.) out of 22 residents reviewed on a therapeutic diets.

Inspectors wroteBased on observations, facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for four of four residents reviewed for respiratory care (Residents 14, 31, 32 and 111). Findings Include: Review of facility policy titled Aerosol Therapy, with a revision date of Mach 21, 2016, revealed, in part, to wash and air dry the nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) after use. When nebulizer equipment is dry, place it back in labeled plastic bag. Plastic bag will have the date that the equipment was opened on the outside of the bag Change aerosol unit, mouth piece, tubing and plastic bag on a weekly basis and label with date. [...]

Inspectors wroteBased on observation, review of facility policy, and interview it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area and one of one nourishment pantry.

Inspectors wroteBased on observations, facility policy review and staff interview, it was determined that the facility failed to ensure each resident the right to a dignified existence during meal service for one of one dining rooms observed. Findings Include: Review of facility policy titled Resident Rights, with a revision date of May 5, 2023, revealed Provide meals to all Residents at each table at the same time. Observation in the dining room during lunch on May 6, 2024, at 12:59 PM, revealed Residents 6, 10, 17, 30 and 50 all sitting at a table. Resident 50 was observed to be eating her lunch, while Residents 6, 10, 17 and 30 had not yet been served their lunch. Additional observations revealed the following: At 1:04 PM, Resident 30 was served her lunch. At 1:08 PM, Resident 6 was served her lunch. At 1:12 PM, Resident 17 was served her lunch. At 1:25 PM, Resident 10 was served her lunch. [...]

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide residents with a copy of the facility's bed-hold policy as a result of a transfer out of the facility for three of four residents reviewed for hospitalization (Residents 10, 14 and 26). Findings Include: Review of facility policy titled Bed Holds and Returns and Therapeutic Leave of Absence, revised September 28, 2022, revealed The Facility will provide information on bed hold requirements to all residents upon admission and again at time of transfer from the Facility. [...]

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 17 residents reviewed (Resident 21 and 32).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 17 residents reviewed (Residents 261)

Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to provide routine drugs to its residents and ensure procedures to assure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 17 residents reviewed (Resident 111). Findings Include: Review of Resident 111's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and obstructive sleep apnea (intermittent airflow blockage during sleep). During an interview with Resident 111 on May 6, 2024, at 10:20 AM, she stated that she wants her nicotine patch but is still waiting for it. She said she was told that the facility has not yet received it. [...]

Inspectors wroteBased on observation, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed on the South unit.

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a safe, clean, and home-like environment in one of one dining room. Findings Include: Observation of the dining room on November 13, 2023, at 10:45 AM, 11:36 AM, 12:30 PM, and 1:35 PM, revealed eight sets of windows with windowsills. Observations of all of the windowsills in the dining room revealed numerous tiny dead black bugs. Further observations revealed additional tiny dead black bugs located on the registers below the windowsills, as well as on the floor below the windows. On November 13, 2023, at 1:45 PM, the Nursing Home Administrator (NHA) was shown the dead bugs in the dining room. At that time, he stated that the bugs appeared within the last week when the weather went from cold to warm. The NHA immediately notified housekeeping to clean the area. 28 Pa. [...]