A list of the most recent deficiencies for Allis Care Center. 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? |
|---|---|---|---|---|
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-12-14 | 2024-01-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-14 | 2024-01-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-14 | 2024-01-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-14 | 2024-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-14 | 2024-01-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-14 | 2024-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-01-24 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-12-14 | 2024-01-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-14 | 2024-01-24 | Y |
| 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 | 2023-12-14 | 2024-01-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-14 | 2024-01-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-14 | 2024-01-24 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-12-14 | 2024-01-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-14 | 2024-01-24 | Y |
| 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 | 2023-12-14 | 2024-01-24 | Y |
| Post nurse staffing information every day. | Health | 2023-12-14 | 2024-01-24 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-14 | 2024-01-24 | Y |
| 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 | 2023-12-14 | 2024-01-24 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-12-14 | 2024-01-24 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-11-29 | 2024-01-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-29 | 2024-01-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-29 | 2024-01-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-11-29 | 2024-01-16 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2023-11-29 | 2024-01-10 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-11-29 | 2024-01-09 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-11-29 | 2024-01-03 | N |
| 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. | Health | 2023-06-08 | 2023-06-09 | N |
| 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. | Health | 2023-06-08 | 2023-06-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-08 | 2023-06-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-08 | 2023-06-09 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-05-31 | 2023-06-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-05-31 | 2023-06-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-31 | 2023-06-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-31 | 2023-06-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-31 | 2023-06-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-05-31 | 2023-06-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-31 | 2023-06-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-05-31 | 2023-06-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-19 | 2023-05-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-19 | 2023-05-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-19 | 2023-05-04 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-19 | 2023-05-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-19 | 2023-05-04 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-19 | 2023-05-04 | Y |
| 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. | Health | 2023-04-19 | 2023-05-04 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-12-12 | 2023-01-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-12 | 2023-01-06 | 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 | 2022-12-12 | 2023-01-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-12 | 2023-01-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-12-12 | 2023-01-06 | 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 | 2022-12-12 | 2023-01-06 | 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 | 2022-12-12 | 2023-01-06 | N |
| 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. | Health | 2022-12-12 | 2023-01-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-12-12 | 2023-01-06 | Y |
| 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 | 2022-12-12 | 2023-01-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-12 | 2023-01-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2023-01-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-12 | 2023-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-12 | 2023-01-06 | Y |
| 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 | 2022-12-12 | 2023-01-06 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Install resident room doors of proper design and width. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-12-07 | 2023-01-06 | 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 | 2022-12-07 | 2023-01-06 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-07 | 2023-01-06 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-06-28 | 2022-08-09 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-28 | 2022-08-09 | Y |
| 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 | 2022-06-28 | 2022-08-09 | Y |
| 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 | 2022-06-28 | 2022-08-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-28 | 2022-08-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-28 | 2022-08-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-28 | 2022-08-09 | Y |
| 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. | Health | 2022-06-28 | 2022-08-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-28 | 2022-08-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-28 | 2022-08-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-28 | 2022-08-09 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-06-28 | 2022-08-09 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-06-28 | 2022-08-09 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-06-28 | 2022-08-09 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Install resident room doors of proper design and width. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-21 | 2022-08-09 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-01 | 2022-03-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-13 | 2022-01-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-13 | 2022-01-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-13 | 2022-01-06 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-13 | 2022-01-06 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-12-13 | 2022-01-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-13 | 2022-01-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-02 | 2021-10-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-02 | 2021-10-01 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-02 | 2021-10-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-02 | 2021-10-01 | Y |
| 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. | Health | 2021-09-02 | 2021-10-01 | Y |
| 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 | 2021-06-21 | 2021-07-21 | Y |
| 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. | Health | 2021-06-21 | 2021-07-21 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-21 | 2021-07-21 | Y |
| 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. | Health | 2021-06-21 | 2021-07-21 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-06-21 | 2021-07-21 | Y |
| Assess the resident when there is a significant change in condition | Health | 2021-06-21 | 2021-07-21 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-21 | 2021-07-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-21 | 2021-07-21 | Y |
| 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. | Health | 2021-06-21 | 2021-07-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-29 | 2021-05-27 | Y |
| 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 | 2021-04-29 | 2021-05-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-29 | 2021-05-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-29 | 2021-05-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-04-29 | 2021-05-24 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-04-29 | 2021-05-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-04 | 2021-03-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-04 | 2021-03-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-04 | 2021-03-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-04 | 2021-03-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-03-04 | 2021-03-19 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-03-04 | 2021-03-19 | Y |
