A list of the most recent deficiencies for Transitions Healthcare Allens Cove. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-11 | 2023-09-26 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-11 | 2023-09-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-01 | 2023-07-11 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-06-01 | 2023-07-11 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-01 | 2023-07-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-01 | 2023-07-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-06-01 | 2023-07-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-06-01 | 2023-07-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-01 | 2023-07-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-06-01 | 2023-07-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-01 | 2023-07-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-06-01 | 2023-07-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-01 | 2023-07-11 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-06-01 | 2023-07-11 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-06-01 | 2023-07-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-01 | 2023-07-11 | N |
| Meet other general requirements. | Fire Safety | 2023-05-08 | 2023-07-05 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-05-08 | 2023-07-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-05-08 | 2023-07-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-08 | 2023-07-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-05-08 | 2023-07-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-08 | 2023-07-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-30 | 2022-08-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-30 | 2022-08-09 | N |
| Respond appropriately to all alleged violations. | Health | 2022-06-30 | 2022-08-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-30 | 2022-08-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-30 | 2022-08-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-30 | 2022-08-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-06-30 | 2022-08-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-30 | 2022-08-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-30 | 2022-08-09 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-30 | 2022-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-30 | 2022-08-09 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-06-30 | 2022-08-09 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-06-30 | 2022-08-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-06-30 | 2022-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-08-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-06 | 2022-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-06 | 2022-07-11 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-06-06 | 2022-07-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-10 | 2021-10-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-15 | 2021-08-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-15 | 2021-08-29 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-15 | 2021-08-29 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-07-15 | 2021-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-08-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-07-15 | 2021-08-29 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-07-15 | 2021-08-29 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-15 | 2021-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-15 | 2021-08-29 | N |
| Dispose of garbage and refuse properly. | Health | 2021-07-15 | 2021-08-29 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-07-15 | 2021-08-29 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-07-19 | 2021-08-29 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-07-19 | 2021-08-29 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-07-19 | 2021-08-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-19 | 2021-08-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-19 | 2021-08-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-19 | 2021-08-29 | N |
