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 Galena Stauss Nursing Home during CMS and state inspections, most recent first.
A resident with Alzheimer’s dementia, behavioral symptoms, and multiple comorbidities made repeated allegations that a CNA had molested her during toileting, including describing being pinned against a wall while being cleaned. Staff documented the allegation, obtained statements from the involved CNAs, and internally concluded the claims were unfounded, but did not notify IDPH or local law enforcement. The Administrator/abuse coordinator acknowledged that neither the initial nor subsequent sexual abuse allegations were reported externally, despite the facility’s abuse policy requiring all suspected abuse, including sexually based incidents and any incident where staff are unsure it meets the definition of abuse, to be reported to the state within 24 hours with a completed investigation within 5 days.
A resident with multiple chronic conditions and documented oral pain was seen by a dentist, who identified significant decay with periapical radiolucency and referred the resident for oral surgery, recommending prompt comprehensive follow-up. The resident returned from the dental visit without paperwork, and facility staff did not obtain visit information or clarify follow-up needs. A subsequent dental follow-up appointment, which the resident and transportation service had arranged, was cancelled by the facility on the day of the visit due to lack of an available staff escort, and it was not rescheduled. Nursing, transportation, social services, and administrative staff gave inconsistent accounts and did not coordinate to ensure the resident’s follow-up dental care, while the resident continued to receive PRN ibuprofen and Tylenol for oral pain.
A resident with cognitive impairments was observed groping another resident's breast in the dining room, an incident witnessed by a CNA who intervened and reported it. The female resident, who has aphasia and cognitive deficits, did not verbally respond. The facility's LPN was present but did not intervene until informed by the CNA. The facility's abuse prevention policy mandates protection from such abuse.
The facility did not submit the required quarterly reports to the PBJ for a specified period in 2024. The Administrator acknowledged the oversight, noting that corporate staff typically manage submissions but failed to do so this time. The facility lacked a policy for PBJ reporting and had been notified by IDPH about the issue.
The facility failed to implement its Legionella management policy, potentially affecting all 44 residents. The Administrator and Infection Preventionist admitted that no water management program, diagrams, surveillance, or testing processes had been completed or initiated. The facility's policy aimed to establish a water management program and surveillance process to reduce infection risks, but these objectives were not met.
The facility failed to properly assess and manage non-pressure wounds for two residents, leading to deficiencies in wound care. One resident's wound was not documented or treated in a timely manner, and the physician was not notified promptly. Another resident's wound assessments were not documented as required. The Interim DON acknowledged poor wound charting and failure to follow the facility's policy on wound care.
A resident's pressure injury was not properly assessed or treated, with significant gaps in documentation and lack of physician notification. The facility failed to conduct timely wound assessments and did not have physician-prescribed treatments until late September, despite the wound's presence since early August. The DON acknowledged the lapses in care and documentation, which were inconsistent with the facility's policy.
The facility failed to replace oxygen tubing monthly for two residents with obstructive sleep apnea and other health conditions. Both residents were observed using oxygen tubing without any indication of when it was last changed, and there was no documentation or physician orders for equipment maintenance. The facility's policy required monthly changes, but this was not followed.
A facility failed to ensure that only licensed staff administered Nystatin Powder to a resident. A CNA incorrectly applied the medicated powder to a resident's buttocks instead of the groin, contrary to the physician's order. The DON confirmed that only nurses should administer such medications, and the powder was misapplied to a wound rather than the intended area.
A resident with diabetes was allowed to choose her insulin dose, deviating from the prescribed sliding scale orders. The LPN administered 15 units of insulin instead of the 10 units indicated by the resident's blood sugar level, and this was not documented in the MAR. The DON confirmed that the resident's physician was aware of her refusal to comply with the sliding scale, but the facility's policy required documentation and physician notification if orders could not be followed.
The facility failed to store controlled medications for two residents under a double lock system. Lorazepam for agitation and anxiety was found in an unlocked medication refrigerator, contrary to facility policy requiring double locks for controlled substances. An LPN and the Infection Preventionist acknowledged the oversight.
A resident with partial leg amputations and mild cognitive impairment fell and sustained a cervical spine fracture during a transfer using a hoist mechanical lift. The fall occurred due to improper sling placement, as the resident slipped through a gap between the head and leg straps. Staff interviews indicated uncertainty about the sling's positioning, and the facility's policy requires proper use of lifting devices. The incident resulted in the resident experiencing neck pain, later confirmed as a cervical fracture.
A resident with cognitive impairment and amputations experienced a fall from a mechanical lift, resulting in neck pain. The facility failed to notify the physician of the new-onset neck pain promptly, delaying imaging and diagnosis of a neck fracture. Despite the delay, the prognosis and treatment were not negatively impacted.
Two residents reported incidents where an RN failed to treat them with dignity and respect. One resident described a dismissive and loud response from the RN when questioned about a potential trip hazard. Another resident recounted a past issue with the RN's loud and disrespectful behavior. Both residents had intact cognition, and the facility's resident rights brochure emphasizes the right to safety and good care.
A facility failed to implement its abuse policy when an RN did not immediately report an incident where another RN forcibly took an ice cream from a resident and made a derogatory remark. The incident was reported after the weekend, allowing the alleged perpetrator to continue working without intervention. The facility's policy requires immediate removal of the alleged perpetrator, which was not followed.
A facility failed to ensure timely reporting of an alleged abuse incident involving a resident. An RN witnessed another RN take an ice cream from a resident and make a derogatory remark but did not report the incident immediately. The RN reported the incident via email days later, leading to a delay in the facility's required reporting to the state.
Failure to Report Resident’s Sexual Abuse Allegations to State and Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report a resident’s allegation of sexual abuse to the Illinois Department of Public Health (IDPH) and local law enforcement as required by policy. The resident had multiple diagnoses including congestive heart failure, type 2 diabetes, Alzheimer’s disease, dementia with behaviors, major depressive disorder, and schizotypal disorder, and had refused a formal cognitive assessment, though a surveyor later determined she was alert and oriented to person, place, and time. Her care plan documented Alzheimer’s dementia with visual hallucinations, long-held delusions, agitation, and a history of combative behaviors that had improved over the past quarter. On one occasion, a CNA reported to a nurse that the resident stated a CNA was not allowed in her room because the CNA had “molested” her. In a later interview, the resident again stated that a staff member had molested her, though she declined to identify the person or involve the Ombudsman. The facility conducted an internal investigation documented as an accusation that a CNA molested the resident, with statements obtained from the involved CNAs and a conclusion that the claims were unfounded and non-credible. There was no documentation that IDPH or local police were notified of the allegation. Social Services described the incident as occurring during toileting, when the CNA allegedly pinned the resident against the wall while cleaning her. The CNA involved reported that the resident had first made an allegation in a prior month, after which she was told not to care for the resident and believed there was no investigation. The Administrator, who serves as the abuse coordinator, acknowledged that this situation had been ongoing since an initial allegation earlier in the year and confirmed that neither the initial nor subsequent allegations were reported externally, explaining that they were unsure if the later statement was a new allegation and that if every allegation from this resident were reported, surveyors would be present frequently. This inaction occurred despite the facility’s written Abuse Prevention Policy stating that all incidents of abuse, including sexually based incidents, are to be reported to the state within 24 hours, with a completed investigation within 5 days, and that if staff are unsure an incident meets the definition of abuse, the policy is to report.
Failure to Arrange Follow-Up Dental Care for Resident with Ongoing Oral Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to physician orders and the resident’s preferences and goals by not ensuring a follow-up dental visit for a resident experiencing oral pain. The resident had multiple diagnoses, including congestive heart failure, Type 2 diabetes, Alzheimer’s disease, major depressive disorder, hypertension, and schizotypal disorder, but the facility assessment documented no cognitive impairment and noted delusions. The resident reported having seen a dentist the prior month, being told that four upper teeth needed extraction, receiving antibiotics from a hospital for suspected infection, and relying on ibuprofen for pain relief. Medication administration records showed the resident received ibuprofen and Tylenol 15 times for oral pain over a little more than a month, with most doses occurring in the latter part of that period. Dental records from the 2/19 visit documented that the resident presented with upper anterior tooth pain, had a periapical x-ray showing decay and a periapical radiolucency on tooth #10, and was referred to an oral surgeon for extraction, with a recommendation to return for a full exam and further evaluation of other teeth. The dentist office scheduler later confirmed that the resident had been seen for an urgent care appointment, that oral surgery was needed, and that the resident was a no-show for a scheduled follow-up appointment on 3/4, with no subsequent contact from the facility or the resident to reschedule. Facility staff interviews revealed that the resident had left with a friend for the 2/19 appointment instead of using arranged transportation and returned without any paperwork, leaving staff unaware of what was done or what follow-up was required. Nursing, transportation, social services, and administrative staff provided conflicting and incomplete accounts regarding responsibility for arranging and rescheduling the follow-up dental appointment. Nurses stated that the transportation company required an escort and that the appointment was cancelled when no staff were available to ride with the resident, and that the resident subsequently called 911 seeking transport, resulting instead in a hospital visit. The transportation staff member stated that the resident had independently arranged the follow-up appointment and transportation, but that the facility cancelled on the day of the appointment due to lack of an escort and did not reschedule because no paperwork had been received from the prior visit. The Social Service Director and Administrator both acknowledged that the resident returned from the 2/19 appointment without paperwork and that there were no further appointments scheduled, with the Administrator indicating a belief that the appointment was only for a cleaning and did not need rescheduling. The DON stated that nurses should follow up with providers when residents return without paperwork and that any missed follow-up appointment should have been rescheduled. The facility’s resident appointment policy contained no guidance on staff responsibilities when a resident returns from an appointment without documentation.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident where one resident was observed groping another resident's breast in the dining room. The incident was witnessed by an agency CNA, who reported that the male resident, who has cognitive impairments and physical limitations due to a stroke, was touching and squeezing the female resident's breast. The female resident, who has aphasia and cognitive deficits, did not respond verbally during the incident. The CNA intervened by instructing the male resident not to touch other residents and removed him from the table. The facility's Licensed Practical Nurse (LPN) was present in the dining room at the time and observed the male resident self-propelling his wheelchair towards the female resident with a purpose. The LPN continued with her tasks until the CNA reported the incident. The facility's administrator was informed of the incident later that evening and expressed surprise at the male resident's behavior, noting it was unusual for him. The facility's abuse prevention policy clearly states that all residents should be free from abuse, including sexual abuse by another resident, which includes intentional sexual touching without permission or the ability to consent.
Failure to Submit PBJ Quarterly Reports
Penalty
Summary
The facility failed to submit quarterly reports to the Payroll-Based Journal (PBJ) for the period of April 1 to June 30, 2024. This deficiency was identified through interviews and record reviews. The facility's roster dated October 1, 2024, indicated that there were 44 residents residing in the building at the time. The Administrator, identified as V1, acknowledged the failure to submit the data, stating that the corporate staff usually handle the submission but did not do so for this quarter. The Administrator also mentioned that there was no existing policy regarding PBJ reporting. The facility had already received a notification from the Illinois Department of Public Health (IDPH) regarding this issue.
Failure to Implement Legionella Management Policy
Penalty
Summary
The facility failed to implement its policy regarding Legionella management, which has the potential to affect all residents in the building. The resident census report dated 10/1/24 showed 44 residents currently residing in the building. On 10/3/24, the Administrator stated that they had been working with a hospital infection preventionist on their policy but had not set any plan yet. They acknowledged that they had not completed or initiated any water management program, diagrams, surveillance process, or testing process. The Infection Preventionist also confirmed that no actions regarding Legionella had been taken, and the plan was still in process. The facility's undated policy titled 'Legionella and Waterborne Pathogens Policy' outlined objectives to establish a water management program and surveillance process to reduce the risk of infections due to waterborne pathogens, but these had not been implemented.
Deficiencies in Wound Care Management
Penalty
Summary
The facility failed to properly assess and manage non-pressure wounds for two residents, R10 and R41, leading to deficiencies in wound care. For R10, the facility did not document a wound bed description, measurements, or notifications when a wound was first identified on the coccyx. Despite the wound being noted on 7/11/24, the physician was not notified until 7/16/24, and no treatment orders were in place until 9/27/24. The Interim Director of Nursing acknowledged that the wound charting was poor and difficult to follow, and that the provider should have been notified earlier. The facility's policy requires assessments and notifications, which were not followed in this case. For R41, a wound was identified on 7/13/24, but there were no documented assessments on or before 7/20/24 and 7/27/24, as required by the facility's policy. The Interim Director of Nursing stated that wound assessments are crucial for tracking the progression of wounds and determining the effectiveness of treatments. The lack of documented assessments during this period indicates a failure to adhere to the facility's policy, which mandates regular assessments and documentation of wounds.
Failure to Properly Assess and Treat Pressure Injury
Penalty
Summary
The facility failed to properly assess, treat, and notify the physician regarding a pressure injury for one resident, identified as R10, out of a sample of 13 residents. On multiple occasions, the facility did not conduct timely wound assessments, as evidenced by gaps in documentation. For instance, there was an 11-day gap between assessments in August and a 9-day gap in September. Additionally, the facility did not have physician-prescribed treatments for R10's pressure injury until late September, despite the presence of the wound since early August. The facility's Director of Nursing (DON) acknowledged that wound assessments should be conducted weekly and should include detailed measurements and descriptions. However, R10's assessments were inconsistent, and the documentation was incomplete. The DON also noted that the physician and family should have been notified of the wound when it was first identified, which did not occur. Furthermore, the facility's policy required that wounds be monitored in the treatment book until healed, but this was not adhered to in R10's case. The facility's failure to follow its own policy and procedures for wound care and documentation resulted in inadequate care for R10's pressure injury. The lack of timely assessments and physician involvement potentially delayed appropriate treatment. The DON admitted that the order for R10's dressing change was poorly written and misinterpreted, leading to further lapses in care. This deficiency highlights significant gaps in the facility's wound care management and communication processes.
Failure to Replace Oxygen Tubing Monthly for Residents
Penalty
Summary
The facility failed to ensure that oxygen tubing was replaced monthly for two residents who were receiving oxygen therapy. The first resident, a female with multiple diagnoses including obstructive sleep apnea and heart failure, was observed with oxygen tubing in her nostrils without any indication of when it was last changed. The resident confirmed that she wore her oxygen continuously. The facility's Infection Preventionist highlighted the importance of changing oxygen tubing monthly to prevent moisture and bacteria buildup, but there was no documentation in the resident's treatment administration record to confirm that the tubing had been changed. Additionally, there was no physician order for the care and maintenance of the oxygen equipment, and the resident's care plan did not address oxygen use. Similarly, the second resident, also a female with diagnoses including obstructive sleep apnea and heart failure, was observed with oxygen tubing in use without a date indicating its last change. This resident also reported using oxygen continuously except during showering or toileting. Like the first resident, there was no documentation in the treatment administration record of the tubing being changed, no physician order for equipment maintenance, and no care plan addressing oxygen use. The facility's policy required nasal cannulas and masks to be changed monthly, but this was not adhered to for these residents.
Improper Administration of Medicated Powder by Unlicensed Staff
Penalty
Summary
The facility failed to ensure that licensed staff administered medicated powder to a resident, leading to a deficiency in pharmaceutical services. A resident, identified as R10, had a physician's order for Nystatin Powder to be applied topically to the groin for excoriated areas. However, a skin/wound note indicated that a CNA applied the treatment powder to the resident's buttocks instead of the groin, which was not in accordance with the physician's order. The Director of Nursing confirmed that Nystatin Powder is a medication intended for fungal infections and should only be administered by nurses, not CNAs. Furthermore, the powder was incorrectly used on a buttock wound rather than the prescribed area, highlighting a failure in following proper medication administration protocols.
Failure to Adhere to Insulin Administration Orders
Penalty
Summary
The facility failed to protect a resident from a significant medication error involving insulin administration. The resident, who has diagnoses including type 2 diabetes and chronic kidney disease, was observed to have received an incorrect dose of insulin. The resident's physician's orders specified a sliding scale for insulin administration based on blood sugar levels, but the resident was allowed to choose her insulin dose, which deviated from the prescribed orders. On one occasion, the resident requested and received 15 units of insulin when the sliding scale indicated she should have received 10 units. This deviation was not documented in the medication administration record (MAR), and there was no area for staff to document the administration of the medication. The Licensed Practical Nurse (LPN) involved stated that the resident had a history of choosing her insulin dose and that the facility allowed this practice to continue. The Director of Nursing (DON) confirmed that the resident's physician was aware of her refusal to comply with the sliding scale and that the facility allowed her to manage her insulin as she did at home. However, the facility's policy required documentation of medication administration and notification of the physician if orders could not be followed. The lack of documentation and adherence to the prescribed insulin orders led to the deficiency, as the facility did not ensure safe and accurate medication administration procedures.
Failure to Double Lock Controlled Medications
Penalty
Summary
The facility failed to store controlled medications for two residents, identified as R9 and R12, under a double lock system as required by regulations. R9 had a physician's order for Lorazepam oral concentrate to be administered sublingually as needed for agitation, while R12 had a similar order for anxiety. During an observation, it was noted that the medication refrigerator, which contained both unopened and partially used bottles of Lorazepam for these residents, was not equipped with a lock, nor were the medications stored in a locked container within the refrigerator. A Licensed Practical Nurse (LPN) acknowledged that the Lorazepam had always been stored in the refrigerator without a double lock and expressed uncertainty about the necessity of such a measure. The Infection Preventionist confirmed that all controlled medications should be under a double lock system to prevent diversion and ensure proper administration. The facility's policy mandates that Schedule II-V controlled medications be stored in separately locked, permanently affixed compartments, but this was not adhered to in the case of R9 and R12's medications.
Improper Sling Placement Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to safely transfer a resident using a hoist mechanical lift, resulting in the resident falling and sustaining a cervical spine fracture. The resident, who had partial leg amputations, diabetes, and mild cognitive impairment, was dependent on staff for transfers. During a transfer from bed to chair, the resident fell out of the sling and hit her head, neck, and shoulder on the floor. The incident report indicated that the resident leaned too far to the left and slipped out of the sling, despite attempts by the CNA to brace the fall. Interviews with staff revealed that the CNAs involved in the transfer were unsure if the sling was positioned correctly, which may have contributed to the resident's fall. The CNAs described the resident falling through a gap between the head and leg straps of the sling. The resident began experiencing neck pain the day after the fall, which was later confirmed to be due to a cervical fracture. The physician expressed concern about the fracture and emphasized the expectation for safe mechanical transfers. The Director of Nursing and other staff members suggested that improper sling placement was likely the cause of the fall. The facility's policy on safe resident handling and transfer requires the use of mechanical lifting devices according to instructions and training, with the sling placed appropriately under the patient. The incident highlights a failure to adhere to these procedures, resulting in the resident's injury.
Failure to Notify Physician of Resident's Neck Pain After Fall
Penalty
Summary
The facility failed to notify a resident's physician of new-onset neck pain following a fall from a hoist mechanical lift. The resident, who had partial left and right leg amputation, type 2 diabetes, and mild cognitive impairment, was cognitively intact with a BIMS score of 14 out of 15. After the fall, the resident began experiencing neck pain, but it took at least a week before she was sent out for X-rays. The facility's Serious Injury Incident Report indicated that the resident fell on 8/12/24, and the physician was not notified of the neck pain until 8/21/24, when an X-ray confirmed a fracture of the neck. Interviews with the CNAs involved in the transfer revealed that the resident fell out of the sling and hit her head, neck, and shoulder on the floor. The resident began complaining of neck pain the following day, but the physician was not informed until much later. The facility's policies required notifying the physician of any change in assessment, which was not followed in this case. The physician stated that if he had been notified earlier, he would have sent the resident for imaging sooner, although the delay did not negatively impact the resident's prognosis or change the treatment provided.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by interactions involving two residents and a registered nurse (RN). One resident reported an incident where the RN responded inappropriately when questioned about a potential trip hazard caused by a rug brought in by a neighboring resident's family. The RN reportedly gestured dismissively and spoke loudly, which the resident found undignified. Another resident recounted a past issue with the same RN, who had responded loudly and disrespectfully when the resident answered a question. Both residents involved had intact cognition according to their Minimum Data Set assessments. The facility's brochure on resident rights emphasizes the right to safety, good care, and satisfaction, which was not upheld in these interactions.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy by not immediately protecting a resident from an alleged perpetrator following an incident of alleged abuse. On the evening of April 25, 2024, a Registered Nurse (RN) witnessed another RN, identified as V3, forcibly take an ice cream from a resident, R1, and dispose of it. V3 then handed a tissue to R1 in an angry manner and made a derogatory remark. Despite witnessing this incident, the observing RN, V4, did not report the event immediately, as required by the facility's abuse prevention policy, which mandates the immediate removal of the alleged perpetrator from the facility. The incident was only reported to the facility's administrator, V1, after the weekend, resulting in V3 continuing to work her shift without any intervention. The administrator stated that had the incident been reported immediately, V3 would have been sent home, and an abuse investigation would have commenced right away. The facility's undated Abuse Prevention Policy and Procedure clearly states that it is the responsibility of the Abuse Prevention team and/or shift supervisor to ensure the alleged perpetrator is removed from the facility within minutes of the incident, which did not occur in this case.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that a staff member immediately reported an alleged abuse incident involving a resident. On the evening of April 25, 2024, a Registered Nurse (RN) witnessed another RN, V3, grab an ice cream from a resident, R1, and throw it away, followed by angrily handing a tissue to R1 and making a derogatory remark. Despite witnessing this incident, the RN, V4, did not report it immediately, as required by the facility's abuse prevention policy. Instead, V4 continued with her duties and left the facility without notifying the administrator or any other authority. V4 later reflected on the incident over the weekend and decided to email the administrator on April 28, 2024, acknowledging her delay in reporting the incident. The facility's policy mandates that all abuse incidents be reported to the state within 24 hours, but the report was not filed until April 29, 2024. The delay in reporting was confirmed by the Interim Director of Nursing (DON), who was informed by V4 on the morning of April 30, 2024, and subsequently notified the administrator. The facility's failure to adhere to its abuse reporting policy resulted in a deficiency being cited.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 80 citations issued within 25 miles in the last 12 months — including the 1 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 Galena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Dominic Villa | 8.8 mi | ★★★★★ | 9 | 1 |
| Mill Valley Care Center | 11.2 mi | ★★★★★ | 0 | 0 |
| Mount Carmel Bluffs | 11.7 mi | ★★★★★ | 3 | 0 |
| Harmony Dubuque | 13 mi | ★★★★★ | 10 | 0 |
| Bethany Home | 13.3 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.