The Laurels of Galesburg

Inspectors wroteThis citation pertains to intake 3052819. Based on interview and record review the facility failed to initiate cardiopulmonary resuscitation (CPR) and emergency medical services (EMS) for in 1 of 4 residents (R100) reviewed for acute change of condition, resulting in an Immediate Jeopardy, when on [DATE] R100 who was a full code, was found unresponsive and facility staff did not active EMS or initiate CPR. R100 subsequently was pronounce dead on [DATE] at 6:00am.

Inspectors wroteThis citation pertains to intake 3052819. Based on interview and record review, the facility failed to monitor a nebulizer (medicated breathing treatment) treatment and ensure supplemental oxygen was continuously supplied to one resident (R100) of one resident reviewed for respiratory treatment and continuous oxygen use, resulting in decreased consciousness.

Inspectors wroteThis citation pertains to intakes #2792486Based on interview and record review, the facility failed to ensure facility staff implement the facility abuse policy and procedure for 3 residents (Resident #112, Resident #104, and Resident #102) of 9 residents reviewed for abuse, resulting in incidents of potential abuse not being reported to the abuse coordinator immediately.

Inspectors wroteThis citation pertains to intake #2792486,2735355 and #2793260. Based on interview, and record review, the facility failed to report allegations involving potential abuse, neglect, or mistreatment to the State Agency timely and accurately in 3 (Resident #107, #112, and #100) of 6 residents reviewed for reporting, including an alleged incident of mistreatment when Resident #107 was hit with a medication cart causing a fall with major injury, allegations of abuse (Resident #100 and Resident #112), resulting in the potential delay in actions to maintain the safety of facility residents and for allegations of abuse to not be reported timely and accurately.

Inspectors wroteThis citation pertains to intake #2735355Based on interview and record review, the facility failed to identify and thoroughly investigate situations involving potential abuse for 2 residents (Resident #107 and Resident #112) of 9 residents reviewed for abuse, resulting in the potential for ongoing abuse due to an incomplete investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care in 1 of 4 residents (Resident #100) reviewed for dignity and timely response to resident needs, resulting in frustration and the potential for impaired dignity, infection, falls, and skin breakdown.

Inspectors wroteThis citation pertains to Intake # 2792486 & 2793260. Based on interview, and record review, the facility failed to ensure facility staff provided care that maintains the highest practicable physical and mental well-being for residents with dementia, cognitive deficit, and behaviors in 1 of 6 residents (Resident #100) reviewed for dementia care, resulting in agitation, distress, resistance to care, and the potential for additional care refusals.

Inspectors wroteThis citation pertains to Intake # 2792486 & 2793260. Based on interview, and record review, the facility failed to ensure a complete and accurate medical record in 1 of 13 residents (Resident #100) reviewed for comprehensive/accurate medical records, resulting in incomplete/missing charting related to resident behavioral concerns and skin alterations, the potential for additional behaviors to go unaddressed, and an inaccurate portrayal of resident status.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision and implement interventions to prevent falls for 1 resident (Resident #7) of 6 residents, resulting in a fall, pain, and impaired functional ability due to amputation of right long finger and injury to right ring fingers.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide an environment that promoted a dignified dining experience for 5 residents (R#35, #39, #42, #57, and #7) of 5 residents reviewed for dignity, resulting in feelings of disappointment with the dining experiences.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a quiet homelike environment in resident areas at night as reported by 5 residents (Resident #15, Resident #54, Resident #33, Resident #79, Resident #20) of 18 residents reviewed for environment and as voiced in the confidential Resident Council Meeting resulting in resident dissatisfaction and frustration from constant noise levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record in 7 of 18 residents (Resident #47, #10, #69, #54, #9, #18, & #63) reviewed for comprehensive/accurate medical records, resulting in missing/inaccurate documentation and the potential for a deterioration in resident status.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 9/8/25 at 2:11 PM, Observation of the central supply room found numerous items stored on the floor and underneath the storage racks. These items were personal hygiene products and care items for residents such as gauze and oxygen supplies. On 9/8/25 at 2:21 PM, Observation of the [NAME] Hall spa room found used gloves, a used razor, and a dozen used plastic razor guards, spread on the floor. Further review of the spa room found the underside of the shower bed with excess accumulation of what appeared to be, skin flakes, hair, bowel movement, and dirt debris. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to 1). develop a person-centered care plan for 1 resident (Resident #7) and 2). implement person-centered care plan interventions for 1 resident (Resident #63) of 18 residents reviewed for person-centered care plan development and intervention implementation, resulting in Resident #7 not having a care plan related to hospice services in place and Resident #63 having increased risk for skin breakdown due to not wearing prevalon boot (prevalon pressure-relieving heel protector boot designed to minimize pressure, friction, and shear on the feet, heels, and ankles of non-ambulatory (non-walking) patients).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an orthosis device (a device designed to prevent or prevent the worsening of contractures (the shortening and hardening of muscles, tendons, or other tissues often leading to restricted joint mobility) was used as ordered in 1 (Resident #63) of 2 residents reviewed for mobility resulting in the potential for the worsening of contracture of Resident #63's left hand.

Inspectors wroteBased on interview, and record review, the facility failed to address/implement dietitian recommendations for nutritional supplements in 1 of 7 residents (Resident #10) reviewed for nutrition, resulting in the potential for impaired wound healing.

Inspectors wroteBased on observation and interviews, the facility failed to store trash and refuse containers covered and in a manner that maintains the area to prevent the harborage or feeding of pests. On 9/8/25 at 1:52 PM, Observation of the outside dumpsters, with Maintenance Director (MD) CCC, found the doors pushed open allowing for pests and precipitation to enter. An interview with MD CCC found that staff have a hard time tossing bags of trash into the dumpster unless the doors are opened. Further review of the dumpster area found excess trash, used gloves, and debris on the inside perimeter of the garbage area.

Inspectors wroteBased on interview and record review, the facility failed to track and offer the influenza and pneumococcal vaccines for 3 (Resident #9, #7, and #2) of 5 residents reviewed for immunizations, resulting in the failure to provide documentation of declination of immunizations and residents not being given the opportunity to receive or decline the influenza and/or pneumococcal vaccination.

Inspectors wroteThis citation pertains to intake #MI00149391 Based on interview and record review the facility failed to ensure that residents were free from significant medication errors in 1 (Resident #100) of 2 residents reviewed for medication errors resulting in Resident #100 being transferred to an acute care hospital emergency room for treatment and admission to a medical intensive care unit.

Inspectors wroteBased on interview and record review the facility failed provide a dignified environment and ensure that staff treated residents with dignity and respect in 4 (Resident #105, #104, #106, and #108) of 7 residents reviewed for dignity, resulting in feelings of frustration and the potential for depression, loss of self-worth, and an overall deterioration of psychological well-being.

Inspectors wroteThis citation pertains to intake #MI00149391 Based on interview and record review the facility failed to ensure an incident of neglect (resident received wrong medication) was reported to the State Agency in 1 (Resident #100) of 1 resident reviewed for reporting, resulting in Resident #100 being transferred to an acute care hospital emergency room for treatment and admission to a medical intensive care unit after receiving the wrong medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care in accordance with professional standards in 2 (Resident #101 and #103) of 3 residents reviewed for quality of care, resulting in 1.) Resident #101 receiving an enteral feeding (method of providing nutrition directly into the gastrointestinal tract through a tube) that did not reflect physician orders for 7 days 2.) not being re-weighed timely after a significant weight change 3.) A delayed assessment and treatment for Resident #103's complaints of pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, and store medications in 1 out of 2 medication carts reviewed for medication storage and labeling resulting in the potential for decreased efficacy of medications and the exacerbation of medical conditions.

Inspectors wroteThis citation pertains to intake number MI00147366. Based on interview and record review, the facility failed to ensure 3 (Resident #101, Resident #102, and Resident #103) of 3 residents reviewed for dementia care, were treated in a manner that supported their psychosocial wellness, resulting in the residents experiencing avoidable stress responses to care interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents.

Inspectors wroteBased on observation and interview the facility failed to properly protect the potable water supply from plumbing cross connections. This resulted in the potential for increased illness and possible contamination of the domestic water.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were available and in reach for 2 (Resident #84 and #75) of 20 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate do not resuscitate (DNR) order was updated timely for 1 (Resident #17) of 20 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a clean and homelike environment that was free of pests and odors for one resident (Resident #9) of 20 residents reviewed for environment resulting in potential for decreased satisfaction of living conditions.

Inspectors wroteBased on interview and record review the facility failed to address resident grievance timely in 1 (Resident #61) of 2 resident reviewed for grievances resulting in feelings of frustration and anger related to missing personal items.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification to the State Long-Term Care (LTC) Ombudsman of facility-initiated transfers/discharges since January 2023, resulting in the potential for all residents to be discharged without an advocate who can inform them of their options and rights.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 ( Resident #8 and #17) of 2 residents reviewed for emergency hospital transfer resulting in the potential for unanticipated expense or the loss of desired room placement in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) for a level II OBRA evaluation was completed for 2 (Resident #77 and #27) of 2 residents reviewed for PASARR, resulting in the potential for unmet mental health care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to develop person centered care plans related to antipsychotic and antidepressant use and implement pressure ulcer interventions for 2 (Resident #44, Resident #36) of 20 residents reviewed for person centered care plans resulting in the potential for unmet care needs of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for use of oxygen in 1 (Resident #81) of 2 residents reviewed for respiratory care, resulting in inaccurate settings and the potential for respiratory infection.

Inspectors wroteBased on interview and record review the facility failed to ensure a RN (registered nurse) worked 8 consecutive hours on 4/13/2024, 4/27/2024, 5/25/2024, and 5/26/2024, resulting in the potential for unmet care needs for all residents who resided in the building on those dates.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 (Resident #77) of 3 residents reviewed for behavioral health, received behavioral health care services resulting in the potential for residents to experience a decline in their psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to discontinue psychotropic medications prescribed as needed (PRN), after 14 days and/or document rationale to extend prn psychotropic medication use in 1 (Resident #75) of 6 residents reviewed for unnecessary medications, resulting in the potential for adverse side effects and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.

Inspectors wroteBased on interview and record review the facility failed to ensure complete documentation in treatment administration records for 1 (Resident #36) of 20 residents reviewed for complete documentation in treatment administration records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1.) proper hand hygiene was used during administration of enteral feeding in 1 (Resident #102) of 1 reviewed for enteral feeding; 2.) proper use of personal protective equipment (PPE) by staff for residents in enhanced barrier precautions during showers in facility community shower rooms and 3.) sanitize resident shared equipment between resident use resulting in the potential for the spread of infection, cross contamination and disease transmission for residents residing in the facility.

Inspectors wroteThis citation pertains to intake #MI00144537 and #MI00144432 Based on interview and record review the facility failed to ensure a complete and accurate assessment was completed and documented for 3 ( Resident #101, Resident #110, and Resident #100) of 3 residents reviewed for complete and accurate assessment, resulting in the potential for a lack of monitoring, unnoticed adverse reactions, unnoticed injury, and the potential for a negative impact to the resident's psychosocial well-being.

Inspectors wroteThis citation contains 2 Deficiency Practice Statements, DPS #1 and #2. This citation pertains to intake number MI00142844 DPS#1 Based on interviews, and record review, the facility failed to protect the resident's right to be free from resident to resident verbal and physical abuse for 1 (Resident #100) of 4 Residents reviewed for abuse, resulting in Resident #100 experiencing fear, increased agitation, and requiring inpatient psychiatric hospitalization.

Inspectors wroteThis citation pertains to MI00142844 Based on interview and record review the facility failed to initiate appropriate treatment measures for 1(Resident #100) of 4 residents reviewed for quality of care, resulting in a Resident #100 experiencing increased pain, developing an ankle abscess, sepsis, and requiring hospitalization.

Inspectors wroteThis intake pertains to intakes: MI00141760 & MI00141787. Based on interview and record review, the facility failed to safely utilize hoyer transfer lifts to ensure safety in 1 of 1 resident (Resident #101) reviewed for accidents and hazards, resulting in a leg fracture for Resident #101.

Inspectors wroteBased on interview and record review, the facility failed to maintain the confidentiality of a residents medical condition unless medically necessary in 1 of 3 residents (Resident #100), resulting in the perception that staff would not care for her due to her medical diagnosis and lack of actual care.

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin in 1 of 5 residents (Resident #101) reviewed for reporting, resulting in unreported injury-fractured leg for Resident #101, and the potential for injuries to go unrecognized and reported to the State Agency (SA).

Inspectors wroteBased on observation, interview, and record review the facility failed to 1.) provide adequate supervision to prevent falls with injury in 1 of 6 residents (Residents #63) and 2.) ensure safe transport of residents in a wheelchair with foot pedals in place in 2 of 9 residents (Resident #3 and #42) reviewed for accidents resulting in the potential of injury to residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with their preferred practice/choices to maintain hygiene, activities and the assistance to go outside daily for 4 of 5 residents (Resident #30, #53, #75 & #281) reviewed for self-determination, resulting in feelings of frustration, feeling dirty and the potential for the residents to not meet their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for 4 of 18 residents (Residents #3, #48, #63, and #66) reviewed for care development/implementation, lack of service for residents to maintain their highest practicable physical, mental, and psychosocial well-being and decline in uncommunicated care needs.

Inspectors wroteBased on observations, interview and record review, the facility failed to employ an Activity Director with the required qualifications resulting in the potential for unmet met psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact the residents who choose to participate in structured activities and/or are dependent for their leisure needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs for 4 (Resident #36, Resident #28, Resident #30, and Resident # 53) residents and the potential of of unmet care needs for all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper infection control practices for proper hand hygiene during a wound dressing change for 1 resident (Resident #30) of 4 review for pressure ulcers, and ensure proper infection control measures were implemented for cleaning and disinfecting resident and resident shared equipment, resulting in the increased potential for the development and transmission of communicable diseases and infection in a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of resident rights training requirements for 26 out of 134 employees reviewed for resident rights training resulting in the potential of facility staff violating the rights of all residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of abuse, neglect, and misappropriation training requirements for 6 out of 134 employees reviewed for abuse, neglect, and exploitation training resulting in the potential for all resident at the facility to experience abuse, neglect, and misappropriation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of Quality Assurance and Performance Improvement (QAPI) training requirements for 10 of 134 employees reviewed for QAPI training resulting in the potential for staff to lack knowledge of the elements and goals of the facility's QAPI program, and their role and potential input, with the potential to affect all residents at the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the provision of infection control training for 5 of 134 employees reviewed for infection control training resulting in the potential for potential for the spread of diseases and infectious processes to all residents at the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure the provision of compliance and ethics training for 7 of 134 employees reviewed for compliance and ethics training resulting in the potential for unethical and unprofessional staff conduct which could affect all residents at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide activities of daily living (ADL) care to promote dignity in 1 of 18 residents (Resident #63) reviewed for dignity resulting in the potential for a reasonable person to experience feelings of embarrassment and/or shame.

Inspectors wroteBased on interview and record review, the facility failed to report to the abuse coordinator and thoroughly investigate a resident to resident altercation per facility policy in 2 of 4 sampled residents (Resident #59) reviewed for abuse investigation, resulting in in the potential for additional resident to resident altercations with injury and potential psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) evaluation for a level two OBRA evaluation was completed for one resident (Resident #75) of 18 residents reviewed for PASARR, resulting in the potential for the resident to not receive appropriate mental health treatment and services.

Inspectors wroteBased on interview, and record review, the facility failed to provide services that meet professional standards of practice related to physician orders for 1 of 18 residents (Resident #12) reviewed for professional standards and quality of care, resulting in a delay for laboratory testing and a potential for delay in treatment for a bacterial infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was consistently provided with showers/bathing for 1 of 4 residents (Resident #3) reviewed for activities of daily living, resulting in unmet personal hygiene needs with the potential for isolation, psychosocial harm, skin breakdown, harboring infection, and decreased self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure post dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) assessment and monitoring were completed for 1 (Resident #57) of 1 resident reviewed for dialysis care, resulting in the potential of being unprepared for a decline in resident condition, due to adverse effects of dialysis.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify post-traumatic stress disorder (PTSD), triggers, and develop individualized care plan interventions to mitigate triggers for 2 (Residents #3 and #11) of 18 residents reviewed for trauma informed care, resulting in the potential of re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma.

Inspectors wroteResident #66 Review of an admission Record revealed Resident #66 a female, with pertinent diagnoses which included dementia. Review of a Minimum Data Set (MDS) assessment for Resident #66, with a reference date of 6/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #66 had severe cognitive impairment. A review of Resident #66's Diagnosis list on 7/25/23 revealed a diagnosis of .Unspecified dementia, unspecified severity, with other behavioral disturbance . A review of Resident #66's Care Plan on 7/25/23 revealed no current individual and/or specific care plan in place related to a diagnosis of dementia or any behavioral disturbances. [...]