Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 H & J Vonderlieth Lvg Ctr, The during CMS and state inspections, most recent first.
Opened insulin pens for two residents were found in the med cart without open dates, and an LPN verified they should be dated after opening and are only good for 28 days at room temperature. In addition, two opened tuberculin vials in the med room refrigerator were found expired, even though the product is used for all residents and should be discarded 30 days after opening.
Failure to Implement EBP for Residents With Wounds: The facility did not implement EBP for six residents with open wounds and surgical wounds that required dressings. Staff provided incontinent care and wound treatment to a resident with a coccyx pressure wound without gowns, and no EBP signs were posted outside the affected residents’ rooms. The IP and DON stated that EBP was only used for residents with indwelling catheters or wounds that were infected or non-healing, despite the facility’s EBP protocol stating that gowns and gloves are required for high-contact care, including wound care for any skin opening requiring a dressing.
A resident with dementia, anxiety, and MDD was given multiple psychotropic meds, including duplicate antipsychotics and frequent PRN olanzapine, for yelling, cursing, and other disruptive behaviors. Staff said the resident was usually redirectable and not a danger to self or others, while observations showed lethargy and a decline in transfer ability. The DON confirmed there was no diagnosis to warrant the antipsychotics, and the physician stated the meds could be contributing to the resident’s lethargy and functional decline.
Medication administration errors exceeded the allowed rate when staff failed to follow physician orders for three residents. An LPN prepared a double dose of Tylenol ES instead of the ordered dose, an RN gave insulin from a pen without priming the needle, and another RN crushed omeprazole and gave it with pudding while the resident was already eating lunch, despite the order for the medication to be given before lunch.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles when two residents’ injectable insulin pens were found opened, in use, and not dated. On observation at the medication cart, R1’s Insulin Lispro 100 unit/ml multi-dose pen was 3/4 full and undated, and R38’s Lantus 100 unit/ml multi-dose pen was 1/2 full and undated. The licensed practical nurse verified that both opened multi-dose insulin pens should have been labeled with an open date after opening and that they were only good for 28 days at room temperature. The facility also failed to ensure a multidose tuberculin vial was discarded after expiration. In the north medication room refrigerator, two opened Aplisol (Tuberculin) 5TU vials were found 1/4 full and labeled with an open date, and the nurse verified that tuberculin should be discarded after 30 days of opening. The report states both tuberculin vials were expired and that the product is used for all residents residing in the facility.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for six residents with open wounds and surgical wounds who were reviewed for EBP. The facility’s EBP protocol stated that EBP expands the use of PPE beyond situations where exposure to blood and body fluids is anticipated and requires gowns and gloves during high-contact resident care activities, including wound care for any skin opening requiring a dressing. The protocol also stated that a sign should be placed outside the resident’s room when EBP is required. The weekly pressure wound report documented that one resident had a stage two pressure wound to the coccyx requiring a dressing, and the non-pressure wound report documented that four residents had MASD, one resident had three surgical wounds, and one resident had vascular wounds, all requiring dressings. During observations, a CNA provided incontinent care to the resident with the coccyx pressure wound without wearing a gown, and an RN provided pressure ulcer treatment to that resident without wearing a gown. A tour of the building showed that none of the six residents’ doors had EBP signs posted. The Infection Preventionist stated that only residents with indwelling catheters were in EBP and that residents with wounds did not require EBP unless the wounds were infected or not healing. The DON stated that the residents with open wounds and surgical wounds were not in EBP and that EBP was only required for wounds that were infected or non-healing; after reviewing the policy and sign, the DON stated that EBP should be worn when providing care for residents with wounds.
Unnecessary Psychotropic Medication Use and Chemical Restraint
Penalty
Summary
The facility failed to ensure that a resident with dementia was kept free from unnecessary psychotropic medications and chemical restraints. The resident, who also had diagnoses of anxiety and major depressive disorder, was ordered multiple psychotropic medications, including two forms of olanzapine, Rexulti, Valium, hydroxyzine, lithium, and Depakote. The record also showed repeated PRN olanzapine use for behaviors such as yelling, cursing, hollering, and attempting to get out of bed or strike staff during care. The resident’s progress notes documented several episodes of disruptive behavior, including yelling that people were in the room, cursing at staff, and attempting to throw herself out of her wheelchair or get out of bed. PRN olanzapine was administered multiple times and documented as effective. Staff interviews stated the resident’s behaviors were typically yelling and screaming, often in the afternoon or during care, and that she could usually be redirected. Staff also stated she was not a danger to herself or other residents and was not physically abusive toward residents. Observation and interviews further showed the resident appeared lethargic and drowsy, with staff and family reporting that she had become more tired and had declined in transfer ability, progressing from substantial assistance to full assistance and then dependence for transfers. The DON confirmed the resident did not have a diagnosis to warrant antipsychotic medications and was on duplicate antipsychotic therapy. The physician confirmed that the resident’s Depakote, olanzapine, Rexulti, Valium, and lithium could be contributing to her lethargic appearance and decline in ability to transfer, and stated that the repeated PRN olanzapine injections were too frequent and that her psychotropic medications should be reviewed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to administer medications as ordered for three of 15 residents reviewed during medication pass, resulting in three errors out of 26 opportunities and an 11.5% medication error rate. The facility’s Medication Administration policy states medications are to be accurately administered following physician’s orders, and the insulin training guide states insulin pen needles must be primed before administration. The facility’s Insulin Administration policy also states there should be no air bubbles in the syringe. For one resident, an LPN prepared to give Tylenol ES 500 mg and confirmed she would have given a double dose instead of the ordered dose of 500 mg three times daily. For another resident with type 2 diabetes mellitus with hyperglycemia, an RN dialed an insulin pen to six units and injected the resident without first ensuring the attached needle was primed and air was expelled. For a third resident ordered omeprazole 20 mg 30 minutes before lunch, an RN crushed the capsule contents with other medications, mixed them with chocolate pudding, and gave them to the resident while she was already eating lunch. The DON later stated the omeprazole should have been given on an empty stomach and that the capsule contents should not have been crushed or administered with pudding.
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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 Mount Pulaski
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincoln Village Healthcare | 10.4 mi | ★★★★★ | 8 | 0 |
| St Clara's Rehab & Senior Care | 10.9 mi | ★★★★★ | 1 | 0 |
| Arc At Hickory Point | 18.2 mi | ★★★★★ | 23 | 1 |
| Goldwater Care Clinton | 18.6 mi | ★★★★★ | 53 | 0 |
| Villa Health Care East | 19 mi | ★★★★★ | 5 | 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 August 2026) and official state health department websites.