Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allison Care Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment were involved in an altercation resulting in one sustaining a wrist fracture after being pushed by her roommate, while another resident reported ongoing distress and self-isolation due to inappropriate sexual behaviors and comments from a fellow resident. The facility did not adequately document or address grievances, nor did staff fully recognize or respond to the abuse, failing to protect residents as required by policy.
Three residents with severe cognitive and physical impairments experienced multiple falls, including incidents resulting in fractures and hospitalizations, due to the facility's failure to implement and document timely, person-centered fall interventions. Care plans were not updated after falls, root cause analyses were often missing or delayed, and specific interventions discussed by staff were not reflected in resident care plans. Observations also revealed that some safety devices were not in place as documented.
Three residents experienced significant failures in nutritional care, including severe weight loss, inconsistent weighing, and lack of documentation of meal intake. For two residents, the facility did not consistently provide or document nutritional supplements or alternatives when supplements were refused or unavailable, and failed to update care plans or implement new interventions as weight loss continued. For a third resident, meal intake was not consistently recorded, despite a care plan requiring it. These actions and inactions led to deficiencies in meeting residents' nutritional needs.
Staff failed to follow Enhanced Barrier Precautions for a resident with a urinary catheter, with high-contact care provided without required gowns. Housekeeping staff did not clean high-touch surfaces or follow proper glove and hand hygiene protocols, and unsanitary practices were observed during medication handling when an LPN returned a tablet touched with bare hands to the stock supply. These actions resulted in multiple breaches of infection prevention and control standards.
A resident with a history of schizoaffective disorder and dementia assaulted her roommate over a television volume dispute, resulting in physical harm. The facility failed to prevent this abuse, despite having policies in place to protect residents from such incidents. The victim, who had anxiety and depression, was moved to a different room and placed on 15-minute checks after the incident.
A resident with cognitive impairment and hemiparesis did not consistently receive needed assistance with oral hygiene. Observations showed visible biofilm and debris on the resident's teeth and gums over several days, and dental records documented ongoing poor oral hygiene. Staff interviews and documentation were inconsistent, with multiple days lacking evidence that oral care was provided, despite the resident's need for substantial help.
A resident with severe cognitive and physical impairments was provided a grab bar/bed rail without documented assessment of alternatives or entrapment risk, and without ongoing evaluation of the device's safety or necessity. Staff confirmed the resident required substantial assistance with transfers and had experienced a recent fall, yet the care plan and medical record lacked evidence of person-centered assessment or regular review of the assistive device.
Failure to Protect Residents from Physical and Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents involving four residents. In the first incident, a resident with severe cognitive impairment and multiple medical conditions, including hemiparesis and dementia, was pushed by her roommate, who also had severe cognitive impairment and behavioral disturbances. This push caused the resident to fall, resulting in a wrist fracture, head abrasion, and a bump to the head. The facility's internal investigation documented that the resident was pushed, but ultimately concluded the abuse allegation was unsubstantiated, citing no actual allegation of abuse by either resident, despite clear evidence of physical harm resulting from the altercation. In the second incident, a cognitively intact resident with depression and anxiety reported feeling uncomfortable and fearful due to another resident's behaviors, which included staring, making inappropriate comments, and inappropriate touching. The resident filed a grievance about the behaviors, which led to her being moved to a different room. However, the resident who exhibited the inappropriate behaviors was later moved to a room directly across from the complainant, leading to further distress and self-isolation by the affected resident. The facility did not document the grievance or the subsequent conversations regarding the room changes, and staff were unaware of the full extent of the inappropriate behaviors reported, including the allegation of sexual touching. The facility's policies required all staff to identify and report abuse, and to take every precaution to prevent abuse by anyone, including other residents. Despite this, the facility did not adequately protect the residents involved from physical and sexual abuse, nor did it ensure that grievances and reports of abuse were properly documented and investigated. Staff interviews revealed a lack of awareness and follow-through regarding the reported incidents, and interventions to prevent further abuse were not implemented in a timely manner.
Failure to Implement and Document Person-Centered Fall Interventions After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that three residents at high risk for falls remained free from accidents and that person-centered, timely interventions were implemented and documented following multiple falls. For one resident with hemiplegia and severe dementia, the facility did not update the care plan with new interventions after several witnessed and unwitnessed falls, including a fall that resulted in a right femur fracture requiring hospitalization and surgery. The care plan lacked person-centered strategies, and root cause analyses were either missing or not documented after significant incidents. Staff interviews revealed that specific interventions, such as using preferred caregivers and maintaining visual supervision, were not included in the care plan. Another resident, admitted after a right femur fracture, experienced multiple unwitnessed and witnessed falls, including a fall that resulted in a fracture around existing hardware. The facility did not implement new, individualized fall interventions after these incidents, and care plan updates were delayed or absent. Documentation showed that interventions following falls were often generic or already in place, and root cause analyses were not consistently performed or documented in a timely manner. A third resident with dementia and Alzheimer's disease sustained several falls, including one resulting in a head laceration requiring hospital treatment. The facility failed to update the care plan with new, person-centered interventions after each fall, and interventions such as anti-tip devices for the wheelchair were not implemented as documented. Observations during the survey confirmed the absence of these devices, and the care plan was only updated during the survey, not in response to prior incidents. Facility policy required individualized interventions and ongoing evaluation, but these were not consistently followed for the residents involved.
Failure to Provide Adequate Nutrition and Monitoring
Penalty
Summary
The facility failed to ensure that three residents received adequate care and services to meet their nutritional needs, resulting in significant and severe weight loss for two residents and inconsistent monitoring for a third. One resident with Alzheimer's disease, dysphagia, and hyperthyroidism experienced a 14.5% weight loss over six months. The care plan required weekly weights and one-on-one meal assistance, but the resident was not weighed consistently as directed, and the care plan was not updated when her medication was discontinued. Additionally, when the resident refused or did not consume prescribed supplements, there was no documentation that alternative supplements were provided as required by the care plan. Meal intake documentation was also inconsistent, and new nutritional interventions were not implemented when the resident's weight began to decline again. Another resident with schizoaffective disorder and vascular dementia experienced an 11% weight loss in one month following a hospital stay for knee surgery, and a further 5.8% weight loss in another month after a subsequent hospitalization for a gastrointestinal bleed. The facility failed to obtain a baseline weight upon readmission and did not consistently provide ordered nutritional supplements, such as Magic Cup, due to supply issues. There was no documentation that alternatives were offered when supplements were unavailable, and meal intake records were incomplete, making it difficult to assess the resident's nutritional status during periods of weight loss. A third resident with severe cognitive impairment, dysphagia, and protein-calorie malnutrition had a care plan requiring meal intake monitoring and documentation. However, the facility failed to consistently document the amount of food consumed at meals, with multiple instances of missing records. Staff interviews confirmed that meal intake was supposed to be recorded after each meal, but the registered dietitian acknowledged missing documentation and did not rely on the CNAs' records. These failures in monitoring, documentation, and implementation of care plan interventions contributed to the deficiencies identified by surveyors.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in staff adherence to established protocols. Staff did not consistently follow Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. Despite clear signage and the availability of personal protective equipment (PPE) outside the resident's room, staff including a physical therapist and a certified nurse aide provided high-contact care such as incontinence care and clothing changes while wearing only gloves and not gowns, contrary to both CDC guidance and facility policy. Interviews with staff confirmed a lack of compliance, with some staff acknowledging they forgot to don gowns or were unaware of the full requirements for EBP during high-contact activities. Housekeeping staff also failed to adhere to proper cleaning and sanitizing procedures in resident rooms. Observations revealed that high-touch surfaces such as door handles, light switches, and call lights were not cleaned, and the cleaning sequence did not consistently proceed from clean to dirty areas as recommended. Additionally, housekeepers did not always change gloves or perform hand hygiene after cleaning dirty areas and before handling clean supplies, and one housekeeper used a toilet brush on surfaces outside the toilet bowl. Personal items such as lanyards came into contact with contaminated surfaces, further breaching infection control standards. Staff interviews confirmed knowledge of correct procedures, but these were not followed in practice during the observed cleaning routines. Medication handling practices were also found to be unsanitary. An LPN was observed pouring out more tablets than prescribed and, after picking up an extra tablet with bare hands, returned it to the stock medication container instead of discarding it. Both the LPN and the DON acknowledged in interviews that medications should not be handled with bare hands and that any medication touched in this manner should be discarded, not returned to stock. These actions collectively demonstrate a failure to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of infectious diseases.
Failure to Prevent Resident-on-Resident Abuse
Penalty
Summary
The facility failed to prevent physical abuse of a resident by another resident, resulting in a deficiency. The incident involved two residents who were roommates. One resident, who had a history of schizoaffective disorder and vascular dementia, became agitated over the volume of the television and physically assaulted her roommate. The assault resulted in the victim receiving multiple hits to the head and a skin tear on the left forearm. The altercation was overheard by a CNA, who promptly informed the nursing staff, leading to the separation of the residents. The facility's policy on abuse, dated 5/3/23, emphasized the prevention of abuse by anyone, including other residents. Despite this policy, the facility did not adequately assess or manage the risk of aggression from the assailant, who had a history of mood disturbances and potential triggers for aggression, such as loud environments. The care plan for the assailant included interventions to manage agitation, but these were not effectively implemented to prevent the incident. The victim, who had a history of anxiety and depression, was cognitively intact and required assistance with daily activities. Following the incident, the victim was moved to a different room and placed on 15-minute checks. The facility notified the relevant authorities and documented the incident, but the deficiency highlights a failure to protect the resident from abuse, as required by the facility's policy.
Failure to Provide Consistent Oral Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a resident who was unable to perform activities of daily living independently. Specifically, the facility did not ensure that the resident consistently received assistance with oral hygiene, despite the resident's cognitive impairment, hemiparesis, and limited mobility. The facility's policy required appropriate support and assistance with oral care for residents unable to perform these tasks independently, including frequent oral inspections and reporting changes to nursing staff. Observations over several days revealed that the resident had visible accumulation of biofilm and debris on her teeth, gums, and tongue. Interviews with the resident and staff indicated that the resident sometimes attempted to brush her teeth independently but often required more than set-up or clean-up assistance. Staff interviews were inconsistent, with some stating the resident needed substantial help and others indicating only set-up or cueing was required. Documentation in the electronic medical record was incomplete, with multiple days showing no record of oral care being provided, and oral care was only documented as completed on a few occasions during the review period. Dental records from multiple visits over several months consistently documented poor oral hygiene, including moderate to heavy bleeding, plaque, calculus, gingival recession, and inflammation. Despite these findings, staff and nursing leadership were either unaware of ongoing oral health issues or believed oral care was being performed as required. The lack of consistent assistance and documentation led to the resident not receiving the necessary support to maintain oral hygiene, as evidenced by both direct observation and dental assessments.
Failure to Assess and Document Alternatives and Ongoing Need for Bed Rail
Penalty
Summary
The facility failed to use a person-centered approach in determining the use of a grab bar/bed rail for a resident with significant cognitive and physical impairments. The resident, who was under 65 years old, had diagnoses including hemiplegia, hemiparesis, vascular dementia, and a history of falls. Despite these conditions, the facility did not identify or document alternatives to using a grab bar/bed rail prior to its installation, nor did they document how any alternatives may have failed to meet the resident's needs. The care plan did not include a focus on the grab bar/bed rail, and the resident's electronic medical record lacked evidence of an assessment for entrapment risk related to the device before it was installed. Observations and interviews revealed that the resident required substantial assistance with transfers and was frequently incontinent, with severe cognitive impairment as indicated by a low BIMS score. Staff interviews confirmed that the resident needed help with transfers and that the grab bar was initially installed to aid with these movements. However, the resident's ability to use the device independently had declined, and staff noted that she sometimes attempted to transfer herself, resulting in a recent fall. There was no documentation of ongoing assessments to evaluate the continued safety or necessity of the grab bar/bed rail, and the last assessment for its use was several months prior. The facility's own policy required comprehensive assessment and documentation in the care plan for the use of assistive devices, including evaluation of the resident's physical and cognitive abilities. Additionally, FDA recommendations and professional guidelines emphasize the need for individual assessment, consideration of alternatives, and regular maintenance and evaluation of bed rails. The facility did not adhere to these standards, as evidenced by the lack of documented alternatives, absence of risk assessment for entrapment, and failure to conduct routine reassessments of the device's appropriateness and safety for the resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lakewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Western Hills Health Care Center | 0 mi | ★★★★★ | 0 | 0 |
| Harmony Pointe Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Edgewater Health And Rehabilitation | 1.6 mi | ★★★★★ | 14 | 0 |
| Cedars Healthcare Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Cambridge Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.