Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Allure Of Knox County during CMS and state inspections, most recent first.
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 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.
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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 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 | — | 13 | 5 |
| Marigold Rehabilitation And Health Care Center | 1.5 mi | — | 6 | 2 |
| Seminary Manor | 1.5 mi | — | 5 | 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.