Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allure Of Knox County during CMS and state inspections, most recent first.
Failure to maintain a full-time RN DON as identified in the staffing plan. The facility’s assessment called for a full-time RN DON on dayshift, but the DON was only present about three days per week because he was still fulfilling an outside hospital contract and sometimes worked direct care on the unit. When the DON was absent, the ADON, who was an LPN, attempted to cover DON duties for the 59 residents.
Food Labeling and Sanitizer Concentration Deficiencies: Surveyors observed multiple opened food items in the refrigerator without date labels, including several condiments and produce items, and five bowls of ham salad without preparation dates. Five sanitizer buckets used for cleaning food prep surfaces tested at 0 ppm, and the Cook confirmed the expected sanitizer concentration was 200 ppm.
Infection control oversight was deficient because the facility did not track resident or staff illnesses in surveillance logs and did not use appropriate PPE when handling soiled linens. A resident was in contact isolation for ESBL of a surgical wound, yet laundry staff handled soiled linen without a gown and stated isolation linens were not separated in special bags or barrels. The IP stated employee illness tracking had not been done and that the facility’s logs only tracked resident infections treated with antibiotics.
The facility failed to support psychotropic use with appropriate diagnoses, timely consent, and documented target behaviors for multiple residents. One resident’s Risperidone consent was incomplete and obtained after the med was started, another resident received ABH cream for restlessness and sundowning that staff and the DON said was part of dementia rather than psychosis, and two other residents had psychotropic orders with behaviors that staff and the regional nurse consultant said did not justify the medications.
The facility failed to complete new level II PASRR reviews for residents who had new psych diagnoses or significant psychiatric changes. One resident developed dementia with psychotic disturbance and was started on Risperidone, another was diagnosed with delusional disorder and later placed on Abilify with reported hallucinations and increased behaviors, a third had psychosis and antipsychotic orders without a new PASRR after admission, and a fourth had dementia with psychotic disturbance with Seroquel and clonazepam orders. Staff and leadership confirmed the missing PASRR reevaluations.
A facility failed to ensure that residents with indwelling urinary catheters had drainage bags covered with privacy/dignity bags. Three residents were observed with catheter bags hanging below wheelchairs and visible urine in the dining room, hallway, and in a resident room; one resident had an empty dignity bag present but the catheter bag itself was still uncovered. The DON confirmed that catheter drainage bags should always be covered for dignity and privacy.
Medications Left at Bedside Without Self-Administration Approval: A resident was observed in bed with multiple morning meds sitting in a clear lid on the bedside table after staff assisted with morning cares. An LPN identified the meds as including cranberry, Lyrica, hydrocodone/APAP, duloxetine, Lasix, losartan, tizanidine, and spironolactone, and the MAR showed they were administered that morning. The Administrator stated meds are not to be left in the room and must be administered by a nurse who watches the resident take them, but the EMR had no self-administration assessment and the care plan did not document approval for bedside self-administration.
Failure to provide and document a Bed Hold Notice for a resident transferred to the hospital. The Administrator could not locate evidence that the notice was sent with the resident or reviewed with the POA, and the RN consultant confirmed it should have been provided and documented in the EMR. The Social Services Director stated no bed hold notification was communicated to the POA.
Care plan lacked measurable interventions for significant weight loss. A resident with dementia/Alzheimer's disease had a 10% wt loss over 3 months, and a dietary note documented a supplement order, meal intake monitoring, and weekly weights. However, the care plan did not reflect the wt loss, measurable goals, or the supplement initiation, and the DON confirmed the plan did not address the resident's wt loss.
Failure to provide scheduled PROM services: A resident with cerebral palsy and contractures in all extremities was assessed as dependent on all cares and had a care plan for passive ROM to maintain or improve ROM, prevent skin breakdown, and reduce discomfort. The restorative nurse stated the resident had not received PROM since late April, even though PROM was scheduled daily, and the facility's restorative policy required identified residents to receive restorative nursing services including ROM.
A resident receiving continuous O2 via nasal cannula was observed with tubing that was not dated. The resident's care plan did not include oxygen interventions, and the MDS did not document oxygen therapy, despite physician orders for continuous O2 for SOB. The Administrator confirmed the tubing should always be dated.
A resident with ESRD required hemodialysis at a renal dialysis facility three times weekly, but the facility failed to document communication and collaboration with the dialysis facility regarding dialysis care and services. The facility’s policy required nursing staff to share information such as meds, orders, labs, VS, advance directives, fluid management, treatment response, complications, and changes in condition, but the Administrator confirmed there was no written communication from the dialysis facility to the facility nurse.
The facility failed to ensure multi-dose insulin pens were labeled with the date opened for two residents. An LPN observed opened Lispro and Basaglar insulin pens stored in medication cart drawers without date-opened labels, and both LPNs verified the pens were unlabeled.
Survey Results Not Readily Accessible or Posted: The facility failed to keep the state survey binder in a location residents and visitors could easily access and failed to post notice that survey results were available for review. During a resident council meeting, multiple residents said they were unaware of the binder, and the resident council president stated she wanted to know where it was. An ADON/Activity Director said she was not aware of the binder location, and the binder was later found behind the receptionist desk on top of a filing cabinet, with no signage in the lobby or hallways.
Failure to post daily nurse staffing information and census was identified when surveyors observed that the required staffing sheet was not posted in the facility for residents and visitors to see. The receptionist confirmed the RN, LPN, and CNA staffing information had not been posted and said the Administrator normally posts it but had not gotten around to it yet.
A resident with multiple complex conditions, including COPD, CKD, prior STEMI, right-sided hemiplegia, and dependence on supplemental O2, was found unresponsive and transferred to the hospital with severely elevated BP and later diagnosed with an intracranial hemorrhage requiring intubation and higher-level care. The facility’s policy required prompt notification of the resident’s representative for significant changes and transfers, but the nurse responsible did not notify the POA of the transfer. The POA only learned of the situation from the hospital physician and then called the facility, at which point staff acknowledged the omission and the nurse later admitted she failed to call due to end-of-shift circumstances and competing demands.
A cognitively impaired male resident with a history of elopement risk was able to exit the facility through his window after staff failed to perform required 15-minute checks and did not assess his window or increase supervision, despite being warned by the resident's family member of his intent to escape. The resident was later found unsupervised near railroad tracks, and staff interviews and video evidence confirmed that care plan interventions were not followed.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
A resident with a history of amputation, spinal stenosis, anxiety, and depression did not have pain assessments documented before or after receiving scheduled pain medications, contrary to facility policy. The DON confirmed that pain assessments were not performed or recorded, and the resident reported experiencing pain and delays in medication administration.
A resident with multiple medical conditions experienced significant medication errors, including late and missed doses of pain and other critical medications. The errors were not properly documented, and required notifications and assessments were not completed, resulting in the resident being visibly uncomfortable and anxious.
A resident with a history of amputation, spinal stenosis, anxiety, and depression, who was prescribed scheduled pain medications, did not have pain assessments documented before or after medication administration. The DON confirmed that pain assessments were not completed as required by facility policy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with severe cognitive impairment and a history of agitation was not provided with appropriate interventions or increased supervision, leading to two incidents of physical aggression against other residents, including one resulting in a bleeding laceration. Staff were not educated on increased supervision, communication, or redirection strategies, and individualized care plans were not implemented in a timely manner, resulting in physical harm and risk to others in the dementia unit.
The facility failed to obtain informed consent for psychotropic medications for two residents. One resident's antidepressant was changed without consent from their Health Care Power of Attorney, and another resident was administered Duloxetine without a signed consent form since admission. The facility's policy requires informed consent for such medications.
The facility did not ensure that an RN was scheduled to work for eight consecutive hours on certain days, as required. This deficiency was confirmed through staffing records and interviews, affecting all 44 residents in the facility.
The facility failed to maintain cleanliness in the kitchen, affecting all 44 residents. A large amount of white, crusty build-up was found on the coffee maker's hot water dispenser, and the walk-in cooler had dust and debris on the fan covers, walls, and ceiling. The Dietary Manager confirmed these issues and acknowledged the need for cleaning.
The facility failed to implement all components of their Infection Prevention and Control Program, affecting 44 residents. The policy requires surveillance for infections among all individuals associated with the facility. However, no documentation of employee illness tracking was found, and the DON confirmed that only resident infections were logged.
The facility failed to implement its Antibiotic Stewardship Program, affecting all 44 residents. The Director of Nursing/Infection Preventionist admitted to not using protocols to review clinical signs or lab reports before administering antibiotics, relying instead on physician orders based on staff belief. This lack of adherence to established protocols indicates a significant gap in the facility's infection prevention and control program.
The facility failed to respond to call lights in a timely manner for several residents, as discussed in a Resident Council meeting. One resident reported waiting 20 minutes for assistance after a bowel movement, while another noted that staff behavior changes when the State Agency is present. The Administrator confirmed ongoing concerns about call light response times over several months.
The facility failed to provide the required bed hold policy to residents or their representatives upon hospital transfer, as documented in the cases of four residents. The facility's policy mandates written notice at the time of transfer, but the medical records lacked this documentation, confirmed by the Regional Nurse.
A facility failed to include a plan for oxygen use in a resident's care plan, despite the resident having a physician's order for oxygen administration. The facility's policy requires comprehensive care plans to address all identified needs, but the resident's care plan lacked documentation for oxygen management. This deficiency was confirmed by the DON.
A facility failed to assess and manage a resident's range of motion (ROM) needs, resulting in a deficiency. The resident, with a history of contractures following a stroke, was not provided with necessary equipment or interventions. Staff interviews revealed a lack of awareness and action regarding the resident's ROM needs, with no contracture assessments being completed and the care plan not addressing the contractures.
A facility failed to follow its policy for IV administration through a PICC line by not checking for blood return before administering medication to a resident. An RN administered normal saline and started an IV infusion without aspirating for blood return, contrary to the facility's policy. The DON confirmed that the RN should have checked for blood return.
A resident's symptoms of depression were not addressed by the facility, despite mood assessments indicating moderate to mild depression. The facility's policy requires behavioral health services to maintain residents' mental well-being, but the resident's depressive symptoms were neither documented nor communicated to the DON or physician. Observations showed the resident was withdrawn and dissatisfied, yet no care plan was developed to address these issues.
The facility failed to employ a licensed Administrator, affecting all 52 residents. An AIT was acting as the Administrator without a current or temporary license, as required. The AIT had an expired license from 2007 and was preparing for the Nursing Home Administration exam. An Administrator from a sister facility occasionally assisted but was not full-time. The facility could not provide the AIT's Administrator's license, only a Registered Nurse license.
The facility failed to conduct pressure ulcer risk assessments and implement necessary interventions for three residents, leading to severe deterioration in their conditions. One resident's stage one ulcer worsened to stage four, requiring surgery, while another developed an unstageable heel ulcer due to lack of offloading. A third resident, at high risk, did not have a care plan with pressure-relieving interventions, and staff failed to properly offload heels.
A resident reported $50 missing from their wallet to a CNA, who failed to notify the administrator as required by the facility's policy. Consequently, no investigation was conducted, and the incident was not reported to the state agency or police. The CNA was suspended pending further investigation for not following the reporting procedures.
Failure to Maintain a Full-Time RN DON
Penalty
Summary
The facility failed to ensure the services of a full-time Director of Nursing who is a Registered Nurse, as identified in its staffing plan, affecting all 59 residents in the facility. The Facility Assessment revised 4/13/26 stated that the staffing plan included a DON who is an RN full time on dayshift, and the CMS Form 671 dated 6/8/26 documented that 59 residents resided in the facility. During interview on 5/8/26, the ADON/Infection Preventionist stated the DON was not at the facility because he was completing a contract with another employer and had not been consistently present since beginning employment in April 2026. The ADON also stated she attempted to cover responsibilities when the DON was absent, but she was an LPN and not an RN. On 5/9/26, the DON stated he accepted the position on April 1, 2026, but continued to fulfill a contractual obligation with a local hospital, was present about three days per week, and sometimes worked direct care assignments on the nursing unit, which limited his ability to perform DON responsibilities. On 5/10/26, the Regional Nurse Consultant stated the DON and ADON were responsible for oversight of the facility and that the ADON assumed DON responsibilities when the DON was unavailable.
Food Labeling and Sanitizer Concentration Deficiencies
Penalty
Summary
The facility failed to ensure that quaternary sanitation buckets contained an adequate level of chemical to sanitize kitchen surfaces and failed to ensure that foods in the refrigerator were labeled with the date opened or prepared. The facility’s CMS Form 671 documented that 59 residents resided in the facility. The facility’s Date Marking for Food Safety policy stated that ready-to-eat, time/temperature control for safety foods must be date marked when opened or prepared, and the Wiping Cloths policy required sanitizer rags to be stored in an approved sanitizing solution and maintained at the proper concentration according to manufacturer instructions. During a kitchen tour with the Cook, surveyors observed multiple opened food items in the two-door refrigerator, including a protein shake, chocolate syrup, grape jelly, lemon juice, a partially used onion, and a partially used tomato, that were not labeled with the date opened. Five bowls of ham salad also lacked preparation date labels. In addition, five sanitizer buckets containing water and washcloths were observed in the kitchen; the Cook identified them as sanitizer solutions used for cleaning food preparation surfaces. Testing of all five buckets showed sanitizer concentrations of zero ppm, and the Cook confirmed that opened and prepared food items should be covered and dated and that sanitizer buckets should maintain a sanitizer concentration of 200 ppm.
Infection Control Program Failed to Track Illnesses and Use PPE for Soiled Linens
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program by not performing surveillance to track and monitor resident and staff illnesses and by not using appropriate PPE when handling soiled linens. The facility’s CMS Form 671 dated 6/8/26 documented 59 residents in the building. The Infection Prevention and Control Program policy stated the Infection Preventionist is responsible for oversight of surveillance, staff and resident exposures, and epidemiological investigations, and the Handling Soiled Linens policy stated used linen should be handled using standard precautions and treated as potentially contaminated. Review of the infection control surveillance logs from 1/1/26 through 6/9/26 showed no tracking log of resident illnesses that did not require antibiotic use and no tracking log of employee illnesses. The Infection Control Contact Isolation List showed R62 was in contact isolation for ESBL of a surgical wound. During observation on 6/8/26, the Laundry Aide was handling and putting soiled linen in the washer without a gown, and stated soiled linens from contact isolation rooms were not placed in any different containers or bags and that she never wore a gown or goggles when handling any soiled linens, including linen from contact isolation rooms. The Infection Preventionist stated she had not been tracking employee illness since starting the position, that the facility was not allowed to ask why staff called in, that special bags or barrels were not used for isolation linens, and that laundry staff should be using a gown and gloves when handling all linens.
Inadequate documentation and justification for psychotropic medication use
Penalty
Summary
The facility failed to ensure that residents had appropriate diagnoses, timely and accurate consent, and targeted behaviors to support the use of antipsychotic medications for four residents reviewed for psychotropic medication use. The facility policy stated psychotropic medications should only be used when nonpharmacological interventions are clinically contraindicated and when the medication is appropriate for a resident’s specific, diagnosed, and documented condition. The record review, observations, and staff interviews showed that the documentation for several residents did not support the use of the medications ordered. For one resident, the record showed Risperidone was started for dementia with psychosis, but the care plan did not identify targeted psychotic behaviors and the current record did not document psychosis-related behaviors. Staff stated the resident’s behaviors were anxiety, attention-seeking, and depression, and the DON confirmed the resident was not a harm to self or others and did not display psychotic behaviors. The psychotropic consent for Risperidone was incomplete, did not document the reason for use, diagnosis, or nonpharmacological interventions, and was obtained after the medication had already been started. For another resident, the record showed ABH cream containing Ativan, Benadryl, and Haldol was ordered for frequent restlessness and agitation. The resident was observed quiet, confused, and not displaying behaviors during multiple observations. Staff stated the resident had sundowning, increased agitation and restlessness in the evenings, and was not aggressive toward others. The DON confirmed the resident’s restlessness and agitation were part of the dementia process and were not psychotic in nature. For two additional residents, one received Aripiprazole and Seroquel for schizophrenia with target behaviors listed as repetitive and anxious behaviors and complaints, while staff stated the resident did not have behaviors affecting self or others and only occasionally repeated things. Another resident received Clonazepam and Quetiapine for anxiety and dementia, but behavior tracking records showed no documented behavioral episodes during the review period, and the only behavior staff reported was talking to self. The regional nurse consultant stated the documented target behaviors were not appropriate to support the identified psychotropic interventions and that dementia was not an appropriate diagnosis for psychotropic medication use.
Failure to Reevaluate PASRR After Psychiatric Changes
Penalty
Summary
The facility failed to ensure residents with new psychiatric diagnoses or significant changes in psychiatric status were reevaluated for a level II PASRR screening. The facility’s policy stated that residents with increased behavioral, psychiatric, or mood-related symptoms, or a newly evident serious mental disorder, intellectual disability, or related condition, were to be referred promptly for a level II resident review. In the sample reviewed, four residents had records showing psychiatric changes or diagnoses that were not followed by documentation of a new PASRR review. R4 had a prior level I PASRR screening that found only Anxiety Disorder and no need for a level II evaluation, but the screening also stated that if changes occurred, a new screen must be submitted. R4’s current record showed a diagnosis of Unspecified Dementia with severe Psychotic Disturbance and a start date for Risperidone for dementia with psychosis. The Regional Nurse Consultant confirmed R4 did not have a level II PASRR screening and that the new psych status and antipsychotic use represented a change that should have triggered a new screen. R57’s prior level I PASRR screening identified Anxiety Disorder only, but the current record showed a diagnosis of Delusional Disorder and later initiation of Abilify. Staff confirmed R57 had hallucinations and increased behaviors after a room move, and the DON confirmed a new PASRR screening should have been completed when the new psych diagnosis and antipsychotic medication were added. R7 had a prior level II PASRR from 2023 for schizophrenia, but after admission the record showed psychosis and orders for Aripiprazole and Seroquel for schizophrenia without documentation of a new PASRR review; the Social Services Director and Administrator confirmed the facility did not initiate a new level II PASRR. R17’s record showed diagnoses including dementia with psychotic disturbance, mood disturbance, anxiety, and depression, with orders for Clonazepam and Seroquel, and the Regional Nurse Consultant stated the target behaviors for Seroquel were not appropriate and that a new PASRR should have been initiated on admission.
Failure to Cover Catheter Drainage Bags for Resident Dignity
Penalty
Summary
The facility failed to ensure that residents with indwelling urinary catheters were provided drainage privacy bags to maintain dignity and privacy for three residents reviewed for dignity. The facility’s Catheter Care policy stated that residents with indwelling catheters are to receive appropriate catheter care and maintain dignity and privacy, and that privacy bags will be available and catheter drainage bags will be covered at all times while in use. During observation, R1 was sitting in his room in a wheelchair with a urinary catheter drainage bag hanging below the wheelchair and copper-tinged urine visible in the bag, without a privacy bag covering it. R52 was observed eating lunch in the dining room with a catheter drainage bag hanging below the wheelchair containing a large amount of amber urine and no dignity covering. R51 was observed self-propelling in the hallway with a catheter bag dangling below the wheelchair; although an empty dignity bag was under the wheelchair, the catheter bag was draining yellow urine and was not covered. The DON confirmed that residents with indwelling urinary catheters should have their drainage collection bags covered with a privacy/dignity bag at all times for dignity and because other residents likely do not want to see someone else's urine.
Medications Left at Bedside Without Self-Administration Approval
Penalty
Summary
The facility failed to ensure medications were administered in accordance with its policy and failed to document that one resident was approved to self-administer medications at bedside. During observation on 6/8/2026 at 9:00 AM, the resident was in bed, awake, and had a bedside table over her lap with morning medications sitting in a clear medication lid on the bedside table after staff had assisted with morning cares. At 9:30 AM, an LPN identified the medications as cranberry, Lyrica, Hydrocodone/Acetaminophen, Duloxetine, Lasix, Losartan, Tizanidine, and Spironolactone. The MAR documented that these medications were administered that morning. At 10:00 AM, the Administrator stated these medications are not to be left in the resident's room and are to be administered by a nurse who watches the resident take them. The resident's EMR did not contain a medication self-administration assessment, and the current care plan did not document approval for self-administration at bedside.
Failure to Provide and Document Bed Hold Notice
Penalty
Summary
The facility failed to ensure that a written Bed Hold Notice was provided to the resident representative and documented in the medical record at the time of hospitalization for one resident, R59, out of a sample of 33 residents reviewed for transfer and discharge requirements. The facility’s Bed Hold Notice policy states that written information regarding bed hold practices is to be provided to the resident or resident representative well in advance and at the time of transfer for hospitalization or therapeutic leave. R59’s census record shows the resident transferred to a local hospital on 5/5/26. During an interview on 6/10/26, the Administrator stated a Bed Hold Notice could not be located as having been sent with R59 to the hospital and there was no documentation that it had been reviewed with the resident’s Power of Attorney. The Regional Nurse Consultant confirmed that a Bed Hold Notice should have been provided and documented in the resident’s electronic medical record. The Social Services Director stated that social services did not handle bed hold notifications and did not communicate with R59’s Power of Attorney regarding a Bed Hold Notice.
Care Plan Missing Measurable Interventions for Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss had a care plan with measurable outcomes and interventions to address and prevent further weight loss. R4's weight summary showed a decline from 137.2 pounds on 3/10/26 to 123.4 pounds on 6/6/26, representing a 10 percent weight loss in three months. A nutritional dietary progress note dated 5/26/26 documented R4's weight at 126 pounds, noted a diagnosis of dementia/Alzheimer's disease, and included a recommendation for a medication pass supplement of 120 milliliters twice daily, meal intake of 51-100 percent, and continued weekly weights. R4's care plan dated 4/7/26 did not document the significant weight loss, any interventions, measurable goals, or the initiation of the medication pass supplement. The facility's Weight Monitoring policy stated that individualized care plans should address identified causes of impaired nutritional status, resident-specific interventions, monitoring time frames, and updates when the resident's condition changes or interventions are ineffective. On 6/10/26, the DON confirmed that R4 had suffered significant weight loss and that the care plan did not reflect interventions or a plan of care to address it.
Failure to Provide Scheduled PROM Services
Penalty
Summary
The facility failed to ensure restorative services were provided for one resident reviewed for range of motion. The resident had a diagnosis of cerebral palsy and was documented as having contractures in both upper extremities and both lower extremities. The resident was not interviewable and was observed in bed with an indwelling catheter attached to the right side of the bed. The care plan identified the resident as at risk for further declines in ROM, discomfort, and skin breakdown, and stated that a passive range of motion program had been initiated to maintain or improve ROM, prevent skin breakdown, and reduce discomfort. The facility's restorative nursing policy stated that residents identified through the assessment process would receive restorative nursing services, including passive or active ROM, and that the restorative nurse was responsible for ensuring all elements of each resident's program were implemented. The restorative nurse stated that the resident had not received PROM services since April 29, 2026, even though the resident was scheduled to receive PROM daily. The MDS documented impairment in both upper and lower extremities and that the resident was dependent on all cares, but the required PROM services were not performed as scheduled.
Oxygen Therapy Not Properly Documented or Maintained
Penalty
Summary
Failure to provide safe and appropriate respiratory care was identified for one resident receiving oxygen therapy. The resident was observed in a high-back wheelchair in the dining room with a nasal cannula delivering 3 liters of oxygen, and the tubing was not dated. The resident's physician's orders documented oxygen at 2 to 6 liters via nasal cannula continuously for shortness of breath. The resident's care plan did not document interventions for oxygen use, and the MDS section for special treatments, procedures, and programs did not document oxygen therapy. The facility's Administrator confirmed the oxygen tubing had no date and stated it should always be dated.
Lack of Dialysis Communication Documentation
Penalty
Summary
The facility failed to provide documentation of communication and collaboration with the dialysis facility regarding dialysis care and services for one resident receiving hemodialysis. The facility’s Hemodialysis policy states that licensed nurses will communicate with the dialysis facility by telephone or written format and include information such as medication changes, physician orders, laboratory values, vital signs, advance directives, nutritional and fluid management, dialysis treatment provided, adverse reactions, changes in condition, and fall or transportation concerns. The resident had a physician order documenting end stage renal disease and a care plan stating the resident required hemodialysis at a renal dialysis facility on Monday, Wednesday, and Friday. During interview, the Administrator confirmed that the resident did not have any written communication from the hemodialysis facility to communicate and report to the facility nurse.
Unlabeled Insulin Pens in Medication Carts
Penalty
Summary
The facility failed to ensure multi-dose injectable insulin pens were labeled with the date when opened for two residents, R5 and R56, during review of medication storage and labeling. The facility policy on labeling medications and biologicals states that all medications and biologicals must be labeled in accordance with current state and federal regulations, and that labels for multi-use vials must include the date the vial was initially opened or accessed. On 6/8/26 at 9:30 AM, an LPN was observed at the back hallway medication cart where R5's opened, 1/3 full Lispro Insulin 100 u/ml injector pen was stored in the top drawer without a date opened label, and the LPN verified it was not labeled. On 6/8/26 at 9:35 AM, another LPN was observed at the middle hallway medication cart where R56's opened, 1/2 full Basaglar Insulin 100 u/ml injector pen was stored in the top drawer without a date opened label, and the LPN also verified it was not labeled.
Survey Results Not Readily Accessible or Posted
Penalty
Summary
The facility failed to ensure the State Agency survey results were kept in a location readily accessible to residents and visitors and failed to post a notice that survey results were available for review. The CMS Form 671 dated 6/8/26 and signed by V10 documented that 59 residents resided in the facility. The Ombudsman Resident Rights for People in Long Term Care Facilities booklet stated residents have the right to see reports of inspections by the Illinois Department of Public Health from the last five years and the most recent review of the facility, along with any plan provided to surveyors to correct problems. During a resident group meeting on 6/9/26, R34, R44, and R51 denied being aware of a state agency survey binder or the availability to review those results. R34, who confirmed she was the resident council president, stated she would like to know where the state agency survey binder was so she could review the state inspection results. V12 stated she usually goes over rights with residents in resident council and was not aware of where the state survey inspection binder was located. At 10:25 AM, the state agency survey inspection binder was found on top of a four-drawer filing cabinet behind the receptionist desk and was not freely accessible to residents. The lobby area and hallways did not contain a posting about the state agency survey results being available for review, and V12 confirmed the binder was behind the receptionist desk and that residents would not be able to reach it.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily resident census and direct care staff posting were posted in an area accessible to residents and visitors. The facility’s CMS Form 671 dated 6/8/26 and signed by the Director of Operations documented that 59 residents resided in the facility. The facility’s Nurse Staff Posting Information policy required the nurse staffing sheet to be posted daily at the beginning of each shift and to include the facility name, current date, current resident census, and the total number and actual hours worked by RN, LPN/LVN, and CNA staff directly responsible for resident care. During a tour on 6/8/26 at 9:40 AM, surveyors observed that the direct care staffing and census for 6/8/26 were not posted within the facility. At 9:45 AM, the receptionist verified that the staffing information was not posted and stated that the Administrator normally posts the staffing and had not gotten around to it yet.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Power of Attorney (POA) of the resident’s transfer to the hospital, as required by the facility’s “Notification of Changes” policy. This policy states that the facility will promptly inform the resident, consult the resident’s physician, and notify the resident’s representative when there is a change requiring notification. The resident had multiple significant diagnoses, including COPD, chronic bronchitis, aphasia, Type II diabetes mellitus, chronic kidney disease, neurologic neglect syndrome, right-sided hemiplegia, atherosclerotic heart disease, dependence on supplemental oxygen, GERD, major depressive disorder, anxiety disorder, ST elevation myocardial infarction, hypertension, hypercholesterolemia, dysphagia, and nicotine dependence. On the date of the incident at 9:28 p.m., an aide notified the nurse that the resident was unresponsive. The nurse assessed the resident, performed a sternal rub with no response, and obtained vital signs showing a blood pressure of 200/120, pulse 70, respirations 22, temperature 97.9, oxygen saturation 95, and blood sugar 138, while awaiting EMT arrival. Later, at 1:17 a.m., the nurse documented being informed by phone that the resident had an intracranial hemorrhage, was intubated for airway protection, and was awaiting air transfer to another hospital for a higher level of care. At 1:45 a.m., the resident’s POA called the facility stating she had been contacted by the hospital physician about the resident’s need for surgery due to a brain bleed and asked when the resident had been sent out, noting no one from the facility had informed her. The nurse then spoke with the floor nurse and asked her to call the POA. The resident’s death certificate later documented death from a massive intraventricular hemorrhage due to cerebrovascular accident. In an interview at 2:40 p.m. on a later date, the nurse (V4) confirmed she failed to notify the POA of the transfer, stating it was the end of the shift, she did not call, and it slipped her mind because there was a lot going on.
Failure to Provide Adequate Supervision and Implement Elopement Precautions
Penalty
Summary
A cognitively impaired male resident with a history of Alzheimer's Disease, restlessness, agitation, and a previous elopement attempt was identified as being at high risk for elopement. The resident's care plan included interventions such as a wander guard and 15-minute visual checks, which were to be implemented due to his severe cognitive impairment and prior behaviors. On the evening in question, the resident's family member notified facility staff that the resident had expressed intent to escape through his window. Despite this warning, staff did not immediately assess the resident or his window, nor did they increase supervision beyond the prescribed 15-minute checks. Video surveillance and staff interviews revealed that staff failed to perform the required 15-minute checks as directed by the care plan. No staff were observed entering the resident's room to check on him during the critical period before his elopement. Staff members admitted to not physically checking on the resident every 15 minutes and were unaware of the specific reasons for the increased monitoring. Additionally, staff did not assess the window for potential hazards after being informed of the resident's intentions, and some staff were not trained on how to access or interpret care plans for residents at risk of elopement. As a result of these failures, the resident was able to manipulate the window lock over time and exit the facility through his room window without staff knowledge or supervision. He was later found by staff and police a block away from the facility, near active railroad tracks. The lack of immediate and adequate supervision, failure to follow the care plan, and insufficient staff training directly led to the resident's unsupervised exit and the resulting Immediate Jeopardy finding.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. No further details about the specific actions, inactions, or the condition of the resident(s) at the time of the deficiency are provided in the report.
Failure to Assess and Document Pain Management for Resident Receiving Scheduled Pain Medications
Penalty
Summary
Facility staff failed to assess the pain of a resident who was receiving scheduled pain medications, as required by the facility's pain management policy. The policy mandates that pain management must be provided in accordance with professional standards, the resident's care plan, and their goals and preferences, including regular reassessment for effectiveness and adverse effects. However, review of the medical record for a resident with a history of left below the knee amputation, spinal stenosis, anxiety, and depression revealed no documentation of pain assessment before or after administration of scheduled pain medications, which included hydrocodone, pregabalin, and tizanidine. During an interview, the resident reported being in pain and noted delays in receiving morning medication, particularly when agency nurses were on duty. The Director of Nursing confirmed that pain assessments were not performed or documented prior to or after medication administration, acknowledging that the pain scale was missing from the record. This lack of assessment and documentation represents a failure to follow the facility's own pain management policy and to ensure appropriate pain management for the resident.
Failure to Prevent Significant Medication Errors and Ensure Timely Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by multiple instances where scheduled medications were not administered at the prescribed times or were omitted entirely. The resident, who had a history of left below the knee amputation, spinal stenosis, anxiety, and depression, was observed to be visibly uncomfortable, pale, and anxious while waiting for her morning medications, which were administered over three hours late. On several occasions, documentation was missing regarding the reasons for late or omitted medication administration, and there was no record of the resident's condition at those times. Staff interviews revealed uncertainty about whether medications were given late or simply not documented, and there was no evidence that the physician or other staff were notified of these errors. The resident's Medication Administration Record showed repeated late administration of critical medications, including pain management drugs and antihypertensives, as well as missed doses of Pregabalin. The facility's policy required assessment, documentation, and notification in the event of medication errors, but these procedures were not followed. Staff could not provide clear explanations for the discrepancies, and there was no documentation of monitoring or interventions in response to the errors. The lack of adherence to medication administration protocols resulted in the resident experiencing discomfort and anxiety.
Failure to Assess Pain for Resident Receiving Scheduled Pain Medications
Penalty
Summary
Facility staff failed to assess the pain of a resident who was receiving scheduled pain medications, as required by the facility's pain management policy. The policy mandates that pain management must be provided in accordance with professional standards, the resident's care plan, and their goals and preferences, including regular reassessment for effectiveness and adverse effects. Despite this, there was no documentation of pain assessment before or after the administration of scheduled pain medications for the resident. The resident in question had a medical history including a left below-the-knee amputation, spinal stenosis, anxiety, and depression. On the day of observation, the resident was alert, appeared pale, had a damp hairline, and was breathing rapidly, and reported being in pain while waiting for her morning medication. The resident's medical record showed scheduled orders for hydrocodone, pregabalin, and tizanidine, but lacked any pain assessment documentation related to these medications. The DON confirmed that pain assessments were not performed as required.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse Due to Lack of Interventions and Staff Education
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse after a resident with severe cognitive impairment and a history of agitation and aggression was not provided with appropriate interventions or increased supervision. Despite documented behaviors such as wandering, suspicion, agitation, and combativeness, there was no behavior care plan for aggression in place for this resident until after multiple incidents occurred. Staff were not educated on increasing supervision or on specific interventions following an initial altercation where the resident threw a handheld radio, striking another resident. Subsequently, the same resident was involved in a second incident where he physically shoved a trash can into another resident's face, resulting in a bleeding laceration to the upper and lower lips. Staff interviews revealed that there were no individualized interventions for residents on the dementia unit, and that staff had not been educated on communication, redirection strategies, or monitoring for signs of agitation after the altercation. Additionally, the two residents involved in the altercation continued to have rooms next to each other, despite ongoing conflict and aggressive behaviors. The facility's own policies required the identification, assessment, care planning, and monitoring of residents with behaviors that could lead to conflict or abuse, as well as staff training and ongoing supervision. However, these policies were not implemented as written, and there were system failures regarding care plans, documentation, and communication of interventions to floor staff. The lack of timely and effective interventions resulted in physical harm to a resident and placed all residents in the dementia unit at risk.
Removal Plan
- The DON/Director of Nursing, Social Services Director and designee assessed all residents in memory care to determine their level of risk with the Abuse assessments and Aggressive behavior assessment.
- 15-minute checks for R1 changed to 1:1 supervision.
- R1 was evaluated by V13's team with inpatient hospital evaluation/treatment and review of medications.
- R1's care plan updated with individualized interventions for aggressive behaviors.
- R1 is not to be seated by other residents with activities, dining etc. when agitated.
- Social Services Director, DON and Administrator re-educated staff on Abuse/Neglect & Exploitation policy and Abuse Prevention.
- All Agency staff being in-serviced on Abuse/Neglect & Exploitation policy and Abuse Prevention prior to start of next shift.
- R1's abuse and aggression assessments completed/updated.
- R1's care plan reviewed and revised by facility interdisciplinary team and revisions and interventions communicated to front line staff caring for R1.
- Abuse policies reviewed/revised to include resident to resident altercations.
- Abuse investigation procedures and documentation process reviewed/revised, and Education provided to all staff.
- DON and designee educated Nurse Aids and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director/MDS/Minimum Data Set Coordinator or designee and care plans to be updated as indicated. Staff will be educated on new interventions either verbally or in writing by Care Plan Coordinator or designee.
- An emergency QAPI (Quality Assessment Performance Improvement) meeting was held to develop and implement plans to prevent further resident abuse.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents. For the first resident, diagnosed with Major Depressive Disorder, Bipolar Disorder Depressive State, and Anxiety Disorder, the facility's Medical Director ordered a change in antidepressant medication from Venlafaxine to Sertraline. However, the facility did not document obtaining consent from the resident's Health Care Power of Attorney before initiating the new medication. The Director of Nursing confirmed that consent should have been obtained prior to the medication change. For the second resident, diagnosed with Major Depressive Disorder, Recurrent, Unspecified, the facility administered Duloxetine for depression without a signed consent form. The Regional Nurse Consultant confirmed that the resident had been taking the medication without consent since admission, and the consent form was only signed on the day of the survey. Both cases highlight the facility's failure to adhere to its policy of obtaining informed consent for psychotropic medications.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled to work for eight consecutive hours, seven days a week, as required. This deficiency was identified through interviews and record reviews, which revealed that on specific dates, namely 11/26/24, 12/02/24, and 12/07/24, the facility did not have an RN scheduled for the required duration. The facility's Daily Staffing Assignment Sheets, provided by the Administrator, documented the staffing schedules and confirmed the absence of eight consecutive hours of RN coverage on these days. This oversight has the potential to affect all 44 residents residing in the facility, as indicated by the facility's Long-Term Care Facility Application for Medicare and Medicaid, which was signed by the Administrator.
Kitchen Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, which has the potential to affect all 44 residents residing in the facility. During an observation, a large amount of white, crusty build-up was found around the dispensing spout of the hot water dispenser on the coffee maker. The Dietary Manager confirmed the presence of the build-up and acknowledged the need for cleaning with lime scale. Additionally, the walk-in cooler was observed to have a large amount of dust and debris adhered to the fan covers, as well as the surrounding wall and ceiling. The Dietary Manager also confirmed the presence of dust and debris in the walk-in cooler and stated that it needed to be cleaned.
Failure to Implement Comprehensive Infection Control Program
Penalty
Summary
The facility failed to implement all components of their Infection Prevention and Control Program, which has the potential to affect all 44 residents currently residing in the facility. The facility's policy requires a system of surveillance for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all individuals associated with the facility. However, upon review of the facility's Infection Control Log, no documentation of employee illness tracking and trending was found. The Director of Nursing/Infection Preventionist confirmed that employee illness tracking was not being conducted, and the only infection log maintained was for the residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program, which is designed to optimize infection treatment and reduce adverse events associated with antibiotic use. The policy outlines responsibilities for the Director of Nursing and the Infection Preventionist, including establishing standards for assessing, monitoring, and communicating changes in residents' conditions, ensuring antibiotics are prescribed appropriately, and educating nursing staff. The policy also requires tracking antibiotic use, monitoring adherence to evidence-based criteria, and reviewing antibiotic resistance patterns. However, the Director of Nursing/Infection Preventionist admitted that the facility does not implement protocols to review clinical signs, symptoms, or laboratory reports before administering antibiotics. They also do not use assessment tools or management algorithms to determine the necessity of antibiotics, instead relying on physician orders based on staff belief of need. This deficiency has the potential to affect all 44 residents residing in the facility, as documented in the facility's Long-Term Care Facility Application for Medicare and Medicaid. The lack of adherence to the established antibiotic stewardship protocols indicates a significant gap in the facility's infection prevention and control program. The Director of Nursing/Infection Preventionist's statement highlights the absence of a systematic approach to antibiotic use, which is contrary to the facility's policy that emphasizes the importance of using narrow-spectrum antibiotics and specifying the dose, duration, and indication for use in prescriptions.
Deficiency in Timely Call Light Response
Penalty
Summary
The facility failed to ensure timely responses to call lights for eight residents who attended a Resident Council meeting. During the meeting, residents expressed concerns about staff response times, with one resident recounting an incident where they had to call the receptionist after waiting 20 minutes for assistance following a bowel movement. The staff member who eventually responded did not seem to care, and when the issue was reported, the resident was informed that an audit showed the call light was on for 15 minutes, which the resident still considered too long. Another resident noted that staff behavior changes when the State Agency is present. The Administrator confirmed that concerns about call light response times had been raised by residents for seven consecutive months in the past year. The report highlights a deficiency in the facility's ability to honor residents' rights to a dignified existence and timely assistance, as evidenced by the repeated complaints and the Administrator's acknowledgment of ongoing issues.
Failure to Provide Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives upon transfer to a hospital, as required by their own policy. This deficiency was identified for four residents (R6, R9, R29, and R52) out of a sample of 28. The facility's Bed Hold Notice Upon Transfer Policy mandates that at the time of transfer for hospitalization or therapeutic leave, the facility must provide written notice to the resident or their representative, specifying the duration of the bed-hold policy and information about the resident's return to the next available bed. The medical records of the residents in question did not contain documentation of the required written notice. Specifically, R9 was hospitalized multiple times, and R29, R6, and R52 were each transferred to the hospital, yet none of their records included documentation of the bed hold policy being provided. The Regional Nurse confirmed that if the bed hold policy is not documented in the nursing progress notes, it was not given, indicating a lapse in following the facility's policy.
Failure to Develop Comprehensive Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident's use of oxygen. The facility's policy mandates the creation of a person-centered care plan that includes measurable objectives and timeframes to address a resident's medical, nursing, and psychosocial needs as identified in their comprehensive assessment. However, the care plan for a resident who was observed using oxygen at two liters per nasal cannula did not include any documentation regarding the management of their oxygen use. This oversight was confirmed by the Director of Nursing, who acknowledged that the resident's care plan should have included a plan for oxygen administration.
Failure to Assess and Manage Resident's Range of Motion Needs
Penalty
Summary
The facility failed to adequately assess and manage a resident's range of motion (ROM) needs, leading to a deficiency in care. The facility's policy required quarterly assessments and the development of a care plan to prevent decline in ROM, but these were not conducted for a resident with a history of contractures. The resident, who had a fall resulting in a stroke and subsequent contractures, was not provided with necessary equipment or interventions to maintain or improve her ROM. The resident reported that a splint, previously used to manage her contractures, was broken and never replaced, and no exercises were performed by staff. Interviews with staff revealed a lack of awareness and action regarding the resident's ROM needs. The restorative aid was unaware of the resident's need for a splint, and the registered nurse confirmed that the splint had not been applied for months. The Director of Nurses admitted to not having a restorative nurse in-house and was unfamiliar with contracture assessments. The Director of Rehab confirmed that no staff were completing contracture assessments, and the resident's care plan did not address her contractures, indicating a systemic failure to provide necessary care and equipment.
Failure to Check Blood Return Before IV Administration
Penalty
Summary
The facility failed to adhere to its policy regarding the administration of intravenous (IV) fluids through a peripherally inserted central catheter (PICC) line for a resident. The policy required staff to check for venous blood return before administering IV medication to ensure proper catheter placement. On December 10, 2024, a registered nurse (RN) attached a 10mL normal saline syringe to the resident's PICC line and administered the saline without aspirating for blood return. The RN then connected the IV medication and started the infusion. The RN later stated that they only check for blood return on double lumen PICC lines, not single lumen ones. The Director of Nursing confirmed that the RN should have checked for blood return prior to starting the IV infusion.
Failure to Address Resident's Depression
Penalty
Summary
The facility failed to address a resident's symptoms of depression and develop a care plan with interventions to recognize and treat these symptoms. The facility's Behavioral Health Services Policy mandates that all residents receive necessary behavioral health services to maintain their highest level of mental and psychosocial functioning. However, for one resident, identified as R47, the facility did not adhere to this policy. R47's mood assessments indicated moderate to mild depression, but these findings were not documented in the social service progress notes, nor were they communicated to the Director of Nursing or the resident's physician. This lack of communication and documentation resulted in the absence of a care plan to address R47's depressive symptoms. Observations and interviews revealed that R47 was often withdrawn, expressed dissatisfaction with the facility, and showed no interest in participating in activities. Despite these clear signs of depression, the facility did not take appropriate steps to assess and address the resident's mental health needs. The social services staff member, V8, admitted to not notifying the necessary parties about R47's mood assessment results, and the Director of Nursing confirmed that there was no communication with the physician regarding R47's mood and behavior. This oversight highlights a significant deficiency in the facility's behavioral health care services.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to employ a licensed Administrator, which has the potential to affect all 52 residents residing in the facility. The facility's Department Head List indicated that an Administrator in Training (AIT) was acting as the Facility Administrator. However, the AIT did not possess a current or temporary Administrator's license, as required by the facility's job description and state regulations. The AIT had an expired Administrator's license from 2007 and was in the process of preparing for the Nursing Home Administration exam but had not yet completed the necessary paperwork to obtain a new license. The AIT had also been performing dual roles, acting as both the Administrator and the Director of Nursing until a new Director of Nursing was hired. An Administrator from a local sister facility, who held a valid Administrator's license, occasionally assisted but was not present full-time. The facility was unable to provide documentation of the AIT's Administrator's license or Administrator in Training License, only providing an active Registered Nurse license. This lack of a licensed Administrator was identified through observations, interviews, and record reviews conducted by surveyors.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to perform pressure ulcer risk assessments and implement appropriate interventions for three residents, leading to significant deterioration in their conditions. Resident 1, who was admitted with a stage one pressure ulcer on the left hip, did not receive a pressure ulcer risk assessment or a care plan with pressure-relieving interventions. The ulcer worsened to a stage four, requiring surgical debridement. The facility staff did not document weekly assessments or treatments for the ulcer, and the resident's preference to lie on the left hip was not addressed in the care plan. Resident 2, who was at risk for pressure ulcers, did not have a quarterly Braden Scale assessment completed, and the facility failed to implement a turning and repositioning program. The resident developed an unstageable pressure ulcer on the right heel, which was not offloaded or treated with pressure-relieving boots as required. The ulcer was discovered to be necrotic and required surgical debridement. Despite the resident's deteriorating condition, the facility did not ensure the use of pressure-relieving interventions, and staff failed to apply the necessary protective measures. Resident 3 was identified as high risk for pressure ulcer development but did not have a care plan with pressure-relieving interventions. Observations revealed that the resident's heels were not properly offloaded, as pillows were placed directly under the heels instead of under the ankles and calves. The facility staff, including CNAs, did not elevate the resident's heels off the bed, which is necessary to prevent pressure ulcer development. The lack of appropriate care plans and interventions contributed to the risk of pressure ulcer development for this resident.
Failure to Report Misappropriation of Funds
Penalty
Summary
The facility failed to report an allegation of misappropriation of funds involving a resident, identified as R1, to the administrator, state agency, and local police department. According to the facility's policy on Abuse, Neglect, and Exploitation, any alleged violations must be reported to the appropriate authorities within specified timeframes. In this case, R1 reported to a Certified Nursing Assistant (CNA) that $50 was missing from his wallet. The CNA, identified as V4, acknowledged receiving this report but failed to notify the administrator, V1, as required by the facility's policy. The administrator, V1, confirmed that they were unaware of the missing money report and, as a result, no abuse investigation was conducted, nor was the incident reported to the state agency or police. The failure to report the incident was a direct violation of the facility's policy, which mandates immediate reporting of such allegations. Consequently, V4 was suspended pending further investigation for not adhering to the policy and procedure regarding the reporting of abuse and neglect allegations.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 56 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Galesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allure Of Galesburg | 1.2 mi | ★★★★★ | 14 | 5 |
| Marigold Rehabilitation And Health Care Center | 1.5 mi | ★★★★★ | 6 | 2 |
| Seminary Manor | 1.5 mi | ★★★★★ | 6 | 0 |
| Allure Of Lake Storey | 1.8 mi | ★★★★★ | 1 | 0 |
| Knox County Nursing Home | 5 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 August 2026) and official state health department websites.