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Pine Crest Manor Ratings & Violations

Pine Crest Manor The staff at nursing homes all throughout the United States are provided guidelines, procedures, and protocols to ensure that no resident acquires a bedsore after admittance to the facility. Unfortunately, due to overcrowding and a lack of training, Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants often fail to take appropriate measures to detect and manage a bedsore (pressure wound; pressure ulcer; pressure sore; decubitus ulcer) in its initial stage of development. Sadly, the Mount Morris elder abuse attorneys at Rosenfeld Injury Lawyers LLC have handled many cases where residents have suffered life-threatening conditions by a preventable open wound caused by the negligent actions of their caregivers.

Pine Crest Manor

Pine Crest Manor is a church-related non-profit 125-certified bed Medicare/Medicaid-approved nursing facility providing services to residents of Mount Morris and Ogle County, Illinois. The facility is located at:

414 S. Wesley Ave.
Mount Morris, Illinois 61054
(815) 734-4103

In addition to providing skilled nursing services, Pine Crest Manor offers physical and occupational therapies, speech-language pathology and restorative nursing.

Mount Morris Nursing Home Resident Safety Concerns

Many families review the federal and state nursing home database systems before placing a loved one in a facility to ensure they receive the highest level of health and hygiene care. The sites reflect a history of opened investigations, safety concerns, filed complaints and health violations with results found on numerous sites including

Currently, Pine Crest Manor maintains an overall five out of five available star rating in the Medicare comparative star rating summary system. This includes five out of five stars for quality measures, staffing issues, and health inspections. However, our Mount Morris nursing home neglect attorneys have found numerous safety concerns involving this facility that include:

  • Failure to Provide Every Resident Proper Treatment to Prevent the Development of a New Pressure Wound or Allowing Existing Pressure Wound to Heal

    In a summary statement of deficiencies dated 02/05/2016, a state surveyor made a notation during an annual licensure and certification survey concerning the facility's failure to "identify pressure ulcer before it was an unstageable wound.” In addition, the state investigator noted the facility’s failure to “document weekly measurements and assessments. The facility failed to seek a change in treatments for wounds showing no signs of progress toward healing.”

    This investigation involved a resident who was admitted to the facility with “no skin issues” and a requirement for “extensive assistance with two persons for bed mobility and transfers.” The resident’s 07/16/2015 Braden Scale for Predicting Pressure Sore Risk Score revealed they had a score of 16 or “low risk for pressure ulcer”.

    A review of the resident’s 08/22/2015 Skin Assessment Form revealed that the resident had “an unstageable wound measuring 2.5 centimeters by 2.3 centimeters with necrotic/eschar (black and dead tissue). The nurse’s notes document the wound is located on the right medial heal.” More than five months later on 02/04/2016, a Licensed Practical Nurse providing the resident care stated that “the new open area was reported to [the facility’s Director of Nurses] and she makes recommendations for treatments.” The Licensed Practical Nurse “could not recall the wound was a blister prior to becoming unstageable.” However, “there was no documentation identifying the area as a blister.”

    The investigation noted that the 10/16/2015 Weekly Wound Assessments document that the resident’s “wound remains at 2.5 centimeters by 2.0 centimeters and is blackened. The next skin assessment occurred on 11/06/2015 and documented that the staff was “unable to measure wound.” While the 11/21/2015 Assessment of the wound says that the measurements are unknown but “approximately a little smaller than the size of a quarter” the December 6 and 11th assessments do not document measurements. By 12/19/2015, the skin assessment documents the wound to “be 3.0 centimeters around.”

    During an interview with the nurse at 9:00 AM on 02/04/2016, it was stated that “if a wound is not healing or showing signs of improvement, she would notify the doctor, otherwise the doctor does not assess the wounds unless the staff request.” The nurse also said that “when the wound first appeared it was flat with the skin and blackened.” The nursing staff at Pine Crest Manor failed to follow established state and federal nursing home protocols and the facility’s undated policy titled: Pressure Ulcer Prevention Policy that reads in part:

    “The goal to ensure that a resident who was admitted to the facility without a pressure ulcer does not develop a pressure ulcer, and a resident who has a pressure ulcer receives care and services to promote healing. Evaluation of treatment regimens for existing pressure ulcers for effectiveness/response and any recommendations for treatment regimen changes shall occur at least monthly.”

Mount Morris Illinois Nursing Home Abuse Lawyers

If your loved one has suffered injury or a wrongful death caused by a preventable pressure sore while residing in any Illinois nursing facility, including Pine Crest Manor, Rosenfeld Injury Lawyers LLC can take legal action against all those that cause their harm. Our Ogle County elder abuse attorneys can handle every aspect of obtaining the financial compensation your loved one and family deserves for your damages.

Call our Mount Morris Illinois nursing home abuse law firm at (888) 424-5757 today to speak with our attorneys about all of your legal options. In addition to providing free case evaluations, we accept all personal injury cases for compensation through contingency fee agreements to avoid the need of paying an upfront fee.

Disclaimer: The above inspection findings are take from public sources including the State Department of Health and from Medicare inspection conducted at the facility at least every fifteen months. Rosenfeld Injury Lawyers LLC cannot confirm that the content on this site is the most recent information related to the facilities mentions.

The inspection findings published are not complete. You may find the most up to date information here: or

The deficiencies/citations listed on this page may have been corrected or substantially corrected after the date of the inspection and date of publishing this material. This page is a legal advertisement and a resource of information for visitors. This material is not endorsed by the facility noted or by any governmental agency. Rosenfeld Injury Lawyers LLC does not have any affiliation with the facility.

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