Above 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 Allure Of Walnut during CMS and state inspections, most recent first.
The facility did not complete required PASARR rescreens for two residents after they were newly diagnosed with severe mental illnesses, despite policy requiring prompt referral for Level II review when a serious mental disorder is identified. Previous screenings had indicated no need for further review, but the emergence of new diagnoses was not followed by the mandated reassessment.
A resident with documented mental health diagnoses was admitted with a positive PASARR Level I screen indicating the need for a Level II evaluation. The facility did not complete or document the required PASARR Level II screening, as confirmed by the administrator.
A resident with a Stage III sacral pressure ulcer did not receive the physician-ordered wound care after debridement, as staff applied skin prep instead of the prescribed leptospermum honey and gauze dressing. The nurse was unaware of the new order, and the required supplies had not been obtained, resulting in the treatment not being completed as directed.
A resident with Parkinson's Disease, chronic pain, and lower extremity impairments was not provided with a range of motion (ROM) program, despite documented mobility limitations. The resident reported not receiving encouragement or assistance with ROM exercises, and the medical record did not show any ROM plan. The DON confirmed the absence of a ROM program for the resident.
A resident receiving enteral nutrition via gastrostomy tube had tube feeding equipment that was not properly cleaned, with visible dried feeding residue on the pump and pole, and the tubing in use was not dated as required by facility policy. The resident was NPO due to dysphagia after a stroke and relied entirely on tube feeding for nutrition and hydration.
A resident with a diagnosis of PTSD, along with other mental health conditions, did not have a care plan that addressed the actual trauma or identified possible triggers for their PTSD. Staff interviews confirmed a lack of knowledge regarding the resident's specific trauma or triggers, and the care plan lacked specific goals and interventions related to PTSD, contrary to the facility's trauma-informed care policy.
Two residents requiring Enhanced Barrier Precautions (EBP) for wound and gastrostomy tube care did not receive care in accordance with facility policy. A registered nurse provided high-contact care activities, including wound dressing changes and gastrostomy tube site care, without donning a gown as required by EBP protocols, despite posted signage and physician orders. The nurse confirmed that gowns were not used during these procedures.
A facility failed to prevent a resident-to-resident physical abuse incident and did not update the abuse care plans for the involved residents. One resident with dementia slapped another in a common area, but their care plans remained unchanged, still indicating a low risk for abuse. The facility's policy required care plan updates upon status changes, but this was not done, contributing to the deficiency.
A resident with a history of frequent UTIs was placed on a maintenance dose of antibiotics without a stop date. Despite this, the resident continued to develop UTIs, and the Infection Control Preventionist was unaware of the reason for the prolonged antibiotic use.
The facility failed to administer medications as ordered for three residents, resulting in a 21.9% medication error rate. Errors included incorrect dosages and failure to follow specific administration instructions, confirmed by staff upon review.
The facility failed to identify, track, monitor, and analyze trends in antibiotic use for two residents. The Infection Prevention and Control Monthly Logs lacked documentation for a resident's upper respiratory infection and another resident's urinary tract infection, which was acknowledged as an oversight by the Infection Control Preventionist.
Failure to Complete PASARR Rescreen After New Mental Illness Diagnoses
Penalty
Summary
The facility failed to perform a required PASARR (Pre-Admission Screening and Resident Review) rescreen for two residents after the emergence of newly diagnosed severe mental illnesses. According to the facility's policy, any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition must be promptly referred to the state mental health or intellectual disability authority for a Level II resident review. However, for one resident who was admitted with a diagnosis of Bipolar Disorder, the facility did not conduct a PASARR rescreen after this diagnosis was made. The resident's previous PASARR indicated that no Level II review was required, as there was no serious mental illness at that time. Similarly, another resident with diagnoses including Delusional Disorder, PTSD, Dementia with behavioral disturbance, and General Anxiety did not receive a PASARR rescreen after being diagnosed with a mental illness. The resident's prior PASARR indicated no need for further screening unless a serious mental illness or significant change in treatment needs occurred. In both cases, the administrator confirmed that the required PASARR rescreens were not completed following the new diagnoses.
Failure to Complete Required PASARR Level II Screening
Penalty
Summary
The facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) Level II screening was completed for a resident who was identified as needing further evaluation for serious mental illness or intellectual/developmental disability. According to the facility's policy, all applicants must be screened for such conditions, and a positive Level I screen requires a Level II evaluation prior to admission, with the review to be completed within 40 calendar days of admission. The resident in question had documented diagnoses of Psychotic Disorder with Hallucinations due to a known physiological condition, Anxiety Disorder, and Major Depressive Disorder, all present at the time of admission. The resident's PASARR Level I screen indicated a need for a Level II onsite evaluation, as required by federal law. However, the medical record did not contain documentation that a Level II PASARR screening was ever completed for this resident, a fact confirmed by the facility administrator.
Failure to Provide Physician-Ordered Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when a resident with a Stage III pressure ulcer on the left sacrum did not receive the physician-ordered wound care following a surgical excisional debridement. The wound physician had ordered discontinuation of skin prep and initiation of leptospermum honey and a gauze island with border to be applied once daily and as needed. However, during wound care, a registered nurse cleansed the area and applied skin prep, contrary to the new orders. The nurse was unaware of the updated treatment plan at the time of care. The director of nursing confirmed that the new order had not been processed and the required leptospermum honey was not available at the facility, resulting in the resident not receiving the prescribed treatment. The facility's policy required wound treatments to be provided according to physician orders, including the specified cleansing method, dressing type, and frequency, but this was not followed in this instance.
Failure to Implement Range of Motion Program for Resident with Functional Limitations
Penalty
Summary
A deficiency was identified when a resident with diagnoses including Parkinson's Disease with Dyskinesia, Adult Failure to Thrive, and Chronic Pain, and documented impairments in both lower extremities, was not provided with a range of motion (ROM) program despite having functional limitations. The resident's Minimum Data Set assessment and restorative observations indicated mild to moderate limitations in mobility across multiple joints. During observation, the resident reported that staff did not encourage or assist with any ROM exercises, and the medical record lacked documentation of any ROM program in place. The Director of Nursing confirmed that there was no ROM plan for the resident, despite the need for one.
Failure to Date Tube Feeding Tubing and Maintain Clean Equipment
Penalty
Summary
A deficiency was identified when a resident receiving enteral tube feeding did not have the tubing dated as required, and the equipment used for tube feeding was not kept clean. The facility's policy mandates that feeding tubes be managed according to clinical standards, including infection control precautions to minimize contamination. During observation, the tube feeding administration pump and the wheeled pole at the resident's bedside were found to have multiple areas of dried, light brown substance, which was confirmed by a registered nurse to be dried tube feeding residue. The nurse acknowledged that both the pump and pole needed cleaning. Additionally, the tubing used for the resident's tube feeding was not labeled with the date it was first used, as required by facility policy. The nurse located a label on the tubing, but it was blank and did not contain the necessary date. The resident in question was receiving all nutrition and fluids via gastrostomy tube due to dysphagia following a stroke and was NPO (nothing by mouth) at the time of the observation.
Failure to Implement Specific PTSD Interventions for Resident
Penalty
Summary
The facility failed to implement specific interventions for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident's medical record documented diagnoses including PTSD, insomnia, delusional disorder, dementia with behavioral disturbance, and general anxiety. The Trauma Informed Care Assessment indicated that the resident had experienced traumatic events and suffered from nightmares related to those events. However, the care plan only noted the presence of nightmares and did not address the actual trauma or identify possible triggers for the resident's PTSD. Interviews with facility staff, including the Minimum Data Set Coordinator and the Director of Nursing, revealed that neither staff nor the resident's family knew the specific trauma or triggers associated with the resident's PTSD. The current care plan lacked specific goals and interventions to address the resident's PTSD triggers, despite the facility's policy requiring trauma-informed care that minimizes triggers and re-traumatization.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as required for two residents who were under Transmission Based Precautions. According to the facility's policy, EBP involves the use of gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices. For one resident with a non-pressure wound on the left anterior leg, a registered nurse performed wound care by washing hands and wearing gloves but did not don a gown, despite a posted EBP sign and physician orders indicating EBP should be used. The nurse later confirmed that a gown was not worn during the procedure. Similarly, another resident with a gastrostomy tube had a posted EBP sign and physician orders for EBP. The same registered nurse performed gastrostomy tube care, including site care and flushing the tube, using hand hygiene but without donning a gown. The nurse acknowledged that EBP was required and confirmed that a gown was not used during the care. These actions were observed and verified during the survey, demonstrating non-compliance with the facility's EBP policy.
Failure to Update Abuse Care Plans After Resident Altercation
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident physical abuse and did not reassess or update the abuse care plans for two residents involved in the incident. The incident occurred when one resident, diagnosed with dementia and behavioral disturbances, slapped another resident on the facial cheek in the facility's common area. This altercation was witnessed by a registered nurse, who confirmed that the incident was due to a disagreement between the residents. The care plans for both residents involved in the incident were not updated to reflect the change in their risk status for abuse. Despite the occurrence of the physical abuse, both residents continued to be care planned as being at low risk for abuse, neglect, exploitation, and trauma. The facility's policy required that care plans be revised upon a change in status, but this was not done in a timely manner following the incident. The registered nurse and the social service director confirmed that the abuse risk assessments and care plans had not been updated since the incident. The social service director stated that abuse-specific care plans are typically updated quarterly or during a significant change review, but no new risk assessment or revisions were made following the incident. This lack of timely reassessment and care plan revision contributed to the deficiency in protecting residents from abuse.
Failure to Identify Indication for Prolonged Antibiotic Use
Penalty
Summary
The facility failed to identify the indication for the prolonged duration of use for a resident with a prescribed antibiotic maintenance dose. The resident had a history of frequent urinary tract infections (UTIs) and was placed on a maintenance dose of antibiotics without a stop date. Despite this, the resident continued to develop UTIs, as documented in the care plan. The Infection Control Preventionist was unaware of the reason for the maintenance antibiotic, noting that it had not prevented the resident from getting UTIs. This deficiency was identified through record review and interview, highlighting the lack of proper documentation and rationale for the prolonged antibiotic use.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered by the physician for three residents, resulting in a 21.9% medication error rate. For Resident 4, the Licensed Practical Nurse (LPN) administered incorrect dosages of Baclofen, Eliquis, Glucophage, Tylenol, and Lyrica, and only one drop of Carboxymethylcellulose Sodium Solution in each eye instead of the prescribed two drops. The LPN confirmed the error upon reviewing the instructions on the medication bubble pack after administration. For Resident 27, the Registered Nurse (RN) administered incorrect dosages of Allopurinol, Aspirin, Diltiazem, Vasotec, Glipizide, Potassium Chloride, and Tylenol, and only one drop of Olopatadine HCL in each eye instead of the prescribed two drops. The RN confirmed the error upon returning to the medication cart. For Resident 31, the LPN administered Sucralfate without adhering to the instruction to take it two hours before or after other medications. The LPN confirmed the error upon reviewing the instructions on the medication bubble pack after administration.
Failure to Monitor and Document Antibiotic Use
Penalty
Summary
The facility failed to identify, track, monitor, and analyze trends in antibiotic use for two residents out of a sample of twelve. According to the Infection Prevention and Control Policy and Procedure, the facility is required to document infections, including the date the infection was first suspected, evidence of infection upon admission, type of infection, testing, treatment, outcome, and follow-up. However, the Infection Prevention and Control Monthly Logs for November 2023 and April 2024 lacked documentation for a resident's upper respiratory infection and another resident's urinary tract infection, respectively. The Infection Control Preventionist acknowledged the oversight during a review of the logs.
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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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Nursing homes near Walnut
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor Court Of Princeton | 14.4 mi | ★★★★★ | 1 | 0 |
| Goldwater Care Princeton | 14.9 mi | ★★★★★ | 5 | 0 |
| Rock Falls Rehab & Hlth Care C | 16.1 mi | — | 0 | 0 |
| Citadel Of Sterling,the | 18.4 mi | ★★★★★ | 0 | 0 |
| Allure Of Sterling | 18.5 mi | ★★★★★ | 15 | 1 |
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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.