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🔎 Allis Care Center

Inspection Results


Inspection Overview

Allis Care Center has been cited for a total of 162 deficiencies since we began saving each survey.

In Wisconsin, the average facility has **46.04 deficiencies** per survey cycle. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Survey Date: 2023-06-08
Correction Date: 2023-06-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2023-06-08
Correction Date: 2023-06-09
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: J

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2023-06-08
Correction Date: 2023-06-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-06-08
Correction Date: 2023-06-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-04-19
Correction Date: 2023-05-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-04-19
Correction Date: 2023-05-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2023-04-19
Correction Date: 2023-05-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2023-04-19
Correction Date: 2023-05-04
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2023-04-19
Correction Date: 2023-05-04
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2023-04-19
Correction Date: 2023-05-04
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Survey Date: 2023-04-19
Correction Date: 2023-05-04
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2022-12-12
Correction Date: 2023-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: C

Keep all essential equipment working safely.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Put firmly secured handrails on each side of hallways.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Keep residents' personal and medical records private and confidential.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: C

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: C

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Plan the resident's discharge to meet the resident's goals and needs.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: C

Keep all essential equipment working safely.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: D

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Put firmly secured handrails on each side of hallways.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Keep residents' personal and medical records private and confidential.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: C

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: C

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Make sure that a working call system is available in each resident's bathroom and bathing area.

Survey Date: 2022-06-28
Correction Date: 2022-08-09
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Survey Date: 2022-03-01
Correction Date: 2022-03-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Survey Date: 2022-03-01
Correction Date: 2022-03-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Provide or get specialized rehabilitative services as required for a resident.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Provide or get specialized rehabilitative services as required for a resident.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-12-13
Correction Date: 2022-01-06
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Survey Date: 2021-09-02
Correction Date: 2021-10-01
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: F

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: F

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: E

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2021-06-21
Correction Date: 2021-07-21
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-04-29
Correction Date: 2021-05-27
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-04-29
Correction Date: 2021-05-27
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Survey Date: 2021-04-29
Correction Date: 2021-05-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: J

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe, appropriate pain management for a resident who requires such services.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2021-03-04
Correction Date: 2021-03-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-01-25
Correction Date: 2021-03-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2021-01-25
Correction Date: 2021-03-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2021-01-25
Correction Date: 2021-03-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that residents are free from significant medication errors.

Survey Date: 2021-01-25
Correction Date: 2021-03-04
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-01-25
Correction Date: 2021-03-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Respond appropriately to all alleged violations.

Survey Date: 2021-01-25
Correction Date: 2021-03-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2021-01-25
Correction Date: 2021-03-19
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that residents are free from significant medication errors.

Survey Date: 2021-01-25
Correction Date: 2021-03-04
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2020-11-04
Correction Date: 2020-12-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2020-11-04
Correction Date: 2020-12-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2020-11-04
Correction Date: 2020-12-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2020-09-30
Correction Date: 2020-10-23
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2020-09-30
Correction Date: 2020-10-23
Category: Pharmacy Service Deficiencies
From Complaint: Y


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**