Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Alverno Health Care Facility during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls experienced three unwitnessed falls within four days, starting soon after admission. Despite documented risks and repeated incidents, the facility did not complete a root-cause analysis to identify common factors, as required by its falls management policy.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Drugs and biologicals were not labeled according to professional standards, and were not stored in locked compartments as required, with controlled drugs not kept in separately locked compartments.
The facility failed to follow up on pharmacy recommendations for medication monitoring and gradual dose reductions for four residents. Despite recommendations for GDRs and laboratory monitoring, there was no documentation of these actions being taken. The DON admitted to not reviewing or forwarding the pharmacist's recommendations to the PCP, contrary to the facility's policy on Medication Regimen Review.
The facility failed to label and date food items in the kitchen, leading to several items being found without proper labeling or beyond expiration dates. Staff interviews revealed that the facility uses a program to track outdated food, but the deficiency indicates a failure in consistently following these procedures.
A resident with diabetes did not receive properly administered insulin due to a failure to prime the insulin pen and check its expiration date. An LPN administered insulin without priming the pen, and the pen was used beyond its expiration date. The DON confirmed the pen should have been primed and removed after 28 days.
A resident in a LTC facility was transferred unsafely from a Broda chair to a bed by two staff members without using a gait belt, and the chair was not locked. The resident required two-person assistance for transfers, as noted in their summary, but the care plan lacked specific transfer instructions. Interviews with staff confirmed the omission of safety measures, and the facility's policy did not address this concern.
The facility failed to follow proper infection control practices during insulin administration for two residents with diabetes. Insulin pens were used without cleaning the hub before needle attachment, and gloves were not worn during administration. The facility's Infection Preventionist and DON confirmed these actions were against protocol.
The facility failed to ensure safe and secure medication disposal. A CMA disposed of two pills in the garbage can on the medication cart, leaving them accessible to 18 residents. Staff interviews revealed inconsistent disposal practices, and the DON was unaware of these practices. The facility's policy lacked clear guidelines for medication disposal.
The facility failed to ensure hand-washing sinks were present in three laundry rooms used by staff to handle soiled items, including isolation materials for C. diff. Staff had to use hand sanitizer or access a soiled utility room to wash hands, posing a contamination risk.
The facility failed to respond to residents' call lights within the required fifteen-minute time frame, affecting multiple residents who required substantial assistance. Interviews and observations revealed significant delays, with some residents waiting over an hour for help. Staff were unsure of the expected response time, and the facility's policy lacked clear guidelines.
A resident reported missing cash and gift cards, but the facility failed to document the investigation outcome or reimburse the missing property. The Administrator did not interview staff or communicate with family members, and the facility lacked a formal policy for handling missing or stolen items.
The facility failed to update the PASRR for a newly admitted resident to reflect his diagnoses of unspecified psychosis, anxiety, and depression. The resident's care plan noted behavior changes and aggression, and the social worker admitted to missing the update.
A facility failed to ensure a resident's PRN anti-psychotic medication was reviewed by the PCP every 14 days or discontinued as required. The resident received the medication multiple times after the 14-day period without proper review or renewal, despite staff awareness of the requirement.
Failure to Complete Root-Cause Analysis After Multiple Resident Falls
Penalty
Summary
The facility failed to complete a root-cause analysis after a resident experienced three falls within a four-day period, beginning within 48 hours of admission. The resident had severe cognitive impairment, vision and hearing difficulties, and required staff assistance for ambulation, toileting, and other activities of daily living. The care plan identified a risk for injury related to falls, with a history of falls and generalized weakness. Despite these known risks, the facility did not conduct a root-cause analysis to determine if there was a common factor contributing to the repeated falls. Incident reports documented that the resident's falls were unwitnessed and occurred in her room, often after attempting to transfer or ambulate without assistance and without using the call light. The resident was found on the floor multiple times, sometimes with minor injuries, and was noted to be disoriented and confused at the time of the incidents. Although staff implemented some interventions after each fall, such as posting reminder signs and increasing visual checks, the facility did not follow its own policy requiring evaluation of falls to determine appropriate interventions to prevent future occurrences.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper medication labeling and storage protocols as observed by surveyors. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Gradual Dose Reductions and Monitor Medications
Penalty
Summary
The facility failed to follow up on pharmacy recommendations for the monitoring of medications and gradual dose reduction (GDR) for four residents. Resident #20, with intact cognition, was prescribed duloxetine, an antidepressant, but there was no documentation of a GDR despite a recommendation from a consultation report. Resident #2, also with intact cognition, was prescribed lorazepam, an antianxiety medication, but similarly, there was no documentation of a GDR following a recommendation. Resident #45, with severely impaired cognition, was prescribed fluoxetine, an antidepressant, and the consultation report recommended a GDR, but there was no documentation of this being addressed. Resident #60, with intact cognition and diagnoses of anxiety and depression, was prescribed buspirone and venlafaxine, but the pharmacist's recommendations for a GDR and laboratory monitoring were not documented as addressed. The Director of Nursing (DON) admitted to receiving emails from the pharmacist and placing them in a folder without reviewing or forwarding the requests to the primary care provider (PCP). The facility's policy on Medication Regimen Review (MRR) requires that the consultant pharmacist's recommendations be communicated to the attending physician and other necessary staff, and that the attending physician should address these recommendations by their next scheduled visit. The lack of action in addressing the pharmacist's recommendations for GDR and monitoring led to the deficiency identified in the report.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to food storage guidelines, as observed during an initial kitchen tour. Several food items in the refrigerator were found without labels or dates indicating when they were opened or prepared. Additionally, some items were kept beyond their expiration dates. Specific items included a large bag of lettuce, a bag of french fries, melted butter, corned beef, and various other food items, all lacking proper labeling. The walk-in refrigerator also contained items with expired dates, such as sliced ham and homemade ranch dressing. Interviews with staff revealed that the facility uses a program to track and dispose of outdated food, and the expectation is for all food items to be labeled with the name, date opened, and discard date. The Sous Chef and Dietary Manager acknowledged the labeling and dating expectations, noting that the refrigerators are checked three times per week. However, the deficiency indicates a failure in consistently following these procedures, as evidenced by the unlabeled and expired items found during the survey.
Failure to Prime and Check Expiration of Insulin Pen
Penalty
Summary
The facility failed to ensure proper insulin administration for a resident diagnosed with Diabetes Mellitus, who received daily insulin injections. During an observation, a Licensed Practical Nurse (LPN) did not prime the insulin pen before administering 2 units of Insulin Lispro for a blood sugar level of 168. The insulin pen had a handwritten open date, but the LPN was unable to confirm the expiration date or the necessity of priming the pen before use. The Director of Nursing (DON) later confirmed that the insulin pen should have been primed with 2 units to prevent air from remaining in the needle and that the pen expired 28 days after being opened. The insulin pen used for the resident had exceeded this period and should have been removed from the medication cart. The facility's Licensed Nurse Skill Competency Checklist included steps for insulin administration but did not address checking the expiration date of insulin pens.
Unsafe Transfer Procedure for Resident
Penalty
Summary
The facility failed to ensure a safe transfer for a resident from a chair to a bed, which was observed during a survey. The resident, who was unable to complete a mental status interview and was dependent on assistance for various activities of daily living, was transferred by two staff members without the use of a gait belt. The resident's care plan did not specify the level of transfer assistance required, and the resident summary indicated a need for two-person assistance with transfers. During the transfer, the Broda chair was not locked, and the staff lifted the resident without using a gait belt, contrary to the facility's expected procedures. Interviews with staff, including the Therapy Director and the Director of Nursing, confirmed that the proper procedure for transferring the resident should have included the use of a gait belt and locking the chair. Staff members involved in the transfer acknowledged the omission of these safety measures. The facility's policy on accidents and incidents did not address the specific area of concern related to the transfer process, highlighting a gap in the facility's procedural guidelines.
Infection Control Deficiency in Insulin Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during insulin administration for two residents with diabetes mellitus. Resident #11, who has Type 2 Diabetes Mellitus, was observed receiving insulin injections without the hub of the insulin pen being cleaned prior to needle attachment. Additionally, the nurse did not wear gloves during the administration of insulin, which is against the expected protocol. The nurse acknowledged the oversight during an interview, admitting that she should have cleaned the hub and worn gloves. Similarly, Resident #45, who also receives daily insulin injections, was administered insulin by a nurse who did not clean the hub of the insulin pen before attaching the needle. The facility's Infection Preventionist and Director of Nursing both confirmed that the expectation is for nursing staff to clean the hub of insulin pens and wear gloves during insulin administration to prevent infections. The facility's competency checklists and medication pass review documents also highlight the importance of these infection control practices.
Unsafe Medication Disposal Practices
Penalty
Summary
The facility failed to ensure medications were disposed of in a safe and secure manner. During a medication cart observation, a Certified Medication Aide (CMA) disposed of two pills, Pantoprazole 40 mg and Metoprolol 50 mg, in the garbage can on the medication cart after they missed the medication cup. This action left the medications unsecured and accessible to 18 residents on the floor. The medication cart was also left unattended during this process. Interviews with staff revealed inconsistent practices for medication disposal, with some staff using the Sharps container or garbage can, while others used drug buster stored in the locked medication room. The Director of Nursing (DON) was unaware that staff were disposing of medications in the garbage or Sharps container and expected them to use drug buster. The facility's policy on medication administration, dated May 2008, did not include procedures for medication disposal. This lack of clear guidelines contributed to the inconsistent and unsafe disposal practices observed among the staff.
Lack of Hand-Washing Sinks in Laundry Rooms
Penalty
Summary
The facility failed to ensure a hand-washing sink was present in three laundry rooms that contained washers and dryers used by staff to transfer presorted clothes from laundry hampers into the washer. During a continuous walk-through of the facility, it was observed that the laundry rooms on the first, second, and third floors did not have hand-washing sinks. This deficiency was identified despite the facility having a census of 88 residents. The absence of hand-washing sinks in these areas is critical, especially when handling soiled items such as isolation materials for C. diff, which requires stringent infection control measures including hand-washing with soap and water, as hand sanitizer alone is not effective against C. diff spores. During an interview, a staff member from Environmental Services (EVS) revealed that in her years of working at the facility, the laundry rooms have never had hand-washing sinks. She mentioned that staff use gloves and proper PPE and then use hand sanitizer available on the wall in the room. However, if they needed to wash their hands with soap and water, they would have to touch multiple doors to access the soiled utility room, which poses a risk of contamination. At the time of the survey, no residents had C. diff, but the lack of proper hand-washing facilities in the laundry rooms represents a significant infection control deficiency.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to respond to residents' call lights within the required fifteen-minute time frame, as observed in multiple instances. Resident #19, who had intact cognition and required assistance for various activities, had her call light on for over an hour and twenty minutes without receiving the needed help. She reported that staff often turned off call lights without providing assistance, leading her to keep the light on to ensure her request was addressed. Similarly, Resident #4, who also had intact cognition and required substantial assistance, reported that call lights often took a long time to be answered, sometimes forcing her to use the bathroom on her own to avoid incontinence. Resident #5, who required substantial assistance and had chronic pain and anxiety, experienced significant delays in call light responses. On one occasion, her call light was on for over two hours without being answered, causing her to fall asleep while waiting for assistance to use the bathroom and receive pain medication. Resident #15, who had an indwelling catheter and required substantial assistance, had a documented history of long call light response times, with multiple instances exceeding twenty minutes. Resident #61, with moderately impaired cognition and requiring substantial assistance, also experienced delays, with her call light being on for over twenty minutes on two separate occasions. Interviews with staff and the Director of Nursing revealed that there was no clear policy on the required response time for call lights, and staff were unsure of the expected response time. The facility's policy on answering call lights advised staff to respond as soon as possible but did not specify a fifteen-minute requirement. The Director of Nursing acknowledged that call light audits had been conducted due to complaints, but the issue persisted. The facility's inability to run a call light report from their computer system further complicated the situation.
Failure to Implement Policy for Missing Property
Penalty
Summary
The facility failed to implement their policy when the Administrator addressed a grievance regarding missing property and possible theft for a resident. The resident, who had an intact cognitive status, reported that between $60 to $80 in cash and approximately $300 in gift cards were missing from his room. Despite the resident's report and a police investigation, the facility's progress notes lacked documentation regarding the missing property, the outcome of an investigation, and any information regarding reimbursement. The Administrator acknowledged awareness of the missing property and conducted a 5-day investigation, which included searching the resident's room and interviewing other residents. However, the Administrator did not interview staff about the incident or inquire whether staff were aware of the resident's money and gift cards. The facility did not have a plan to replace or reimburse the missing property, and the Administrator did not communicate with any family members who may have assisted the resident in acquiring the gift cards. Several staff members, including CNAs and the DON, were involved in searching the resident's room and reported the incident to the Administrator. However, there was no formal investigation involving staff interviews, and inconsistencies were noted in the amounts of money and gift cards reported missing. The facility's Resident Handbook stated that the community does not accept responsibility for the loss or theft of money or valuables, and residents were encouraged to keep valuables in a locked and safe place or in a resident trust account.
Failure to Update PASRR with Accurate Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) for a newly admitted resident accurately reflected his admitting diagnosis. The resident was admitted with diagnoses of unspecified psychosis, anxiety, and depression, which were not documented in the PASRR dated prior to admission. The resident's care plan noted behavior changes related to dementia, including delusions and aggression. The facility's social worker acknowledged that the PASRR was not updated to reflect the new diagnoses, despite the resident receiving these diagnoses shortly after admission.
Failure to Review PRN Anti-Psychotic Medication Every 14 Days
Penalty
Summary
The facility failed to ensure that a resident's PRN anti-psychotic medication was reviewed by the Primary Care Provider (PCP) every 14 days or discontinued as required. The resident was prescribed Seroquel 12.5 PRN, and although the initial rationale for its use was documented, there was no follow-up documentation within the subsequent 14 days to justify its continued use. The resident received the medication on multiple occasions after the 14-day period had lapsed without a proper review or renewal by the PCP, specifically on 4/18/24, 4/22/24, 4/24/24, 4/25/24, and 4/29/24. This oversight was identified during a record review and staff interviews, revealing a lapse in compliance with CMS requirements for PRN anti-psychotic medications. The facility's Social Worker acknowledged awareness of the 14-day review requirement but noted the family's insistence on having the medication available for the resident. During interviews, staff members, including a Registered Nurse/MDS Coordinator, confirmed their awareness of the requirement for PRN anti-psychotic medications to be reviewed every 14 days. Despite this knowledge, the facility did not ensure compliance, resulting in the resident receiving the medication without the necessary evaluations and renewals. The facility reported a census of 88 residents at the time of the survey, and this deficiency was identified through a combination of record reviews and staff interviews.
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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 Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eagle Point Nursing And Rehabilitation | 1.4 mi | — | 7 | 0 |
| La Bella Of Morrison | 13 mi | — | 12 | 0 |
| Resthave Home-whiteside County | 13.1 mi | — | 7 | 0 |
| Big Meadows | 16.7 mi | — | 2 | 0 |
| Fieldstone Of Dewitt | 18.2 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.