Allure of Mendota

Inspectors wroteBased on interview and record review the facility failed to ensure money paid to the facility was refunded to the resident or the resident's representative/resident's estate within 30 days following the resident's discharge from the facility. This applies to 3 of 3 residents (R1, R5 and R6) reviewed for discharge in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a certified dietary manager was employed as food service director which applies to all 64 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide restorative services to residents with contractures and/or limited mobility for 4 of 6 residents (R41, R65, R8, R29) reviewed for mobility/range of motion in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure required Personal Protective Equipment (PPE) was worn in rooms of residents on contact, droplet isolation and failed to ensure hands were washed and gloves were changed to prevent cross contamination during incontinence care. This applies to 6 of 17 residents (R11, R17, R40, R58, R41 and R5) reviewed for infection control in the sample of 17.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care in a manner to prevent infection to 1 of 6 residents (R7) reviewed for incontinence care in the sample of 17.

Inspectors wroteBased on interview and record review the facility failed to report an injury of unknown origin to Illinois Department of Public Health (IDPH) for a resident with bruises to her inner thigh area for 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure a thorough investigation was done by interviewing additional residents when a resident had an injury of unknown origin that consisted of bruising to her inner thighs for 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 6.

Inspectors wroteBased on record review and interview, the facility failed to verify a resident's code status prior to starting CPR/Cardio-Pulmonary Resuscitation for one of three residents (R1) reviewed code status in the sample of three.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter bag included a privacy cover and the catheter tubing was off the floor for one (R22) of one resident reviewed for indwelling urinary catheters in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to physician orders and medication instructions for two (R6 and R56) of seven residents reviewed during Medication Administration. This failure resulted in two medication errors out of 26 opportunities resulting in a 7.69% (percent) medication error rate.

Inspectors wroteBased on observation, interview, and record review the facility failed perform assessments, failed to continue to monitor a resident's change of condition, failed to communicate changes in a resident's condition, and failed to provide treatment of a fracture in a timely manner for 1 of 3 residents (R1) reviewed for quality of care in the sample of 7. These failures resulted in experiencing continued pain after a fall on 8/23/24 and a delay in her being sent to the hospital for evaluation and treatment. R1 was transferred to the hospital on 9/5/24 (2 weeks after she fell) and had surgery for a right hip fracture.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely perform a mechanical lift transfer and failed to follow their policy and procedure after a fall for 1 of 3 residents (R1) reviewed for safe transfers in the sample of 7. This failure resulted in R1 falling to the floor, sustaining a right hip fracture, and requiring surgical repair of the fracture.

Inspectors wroteBased on interview and record review the facility failed to provide sufficient staffing to meet resident's needs. This has the potential to affect all residents in the building.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe resident transfers for two (R1 and R2) of three residents reviewed for falls with transfers in a sample of three. This failure resulted in R1 and R2 being sent out to the hospital. R1 suffered from pain and a left hip fracture requiring surgery. R2 suffered from pain and a left hip sprain and sacral contusion.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions for a resident identified at risk of skin breakdown and failed to complete weekly skin assessments for one of one resident (R8) reviewed for pressure ulcers in the sample of 24. This failure resulted in R8 developing unstageable pressure ulcers to R8's bilateral heels.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the designated Infection Control Preventionist completed the specialized training in infection prevention and control. This failure has the potential to affect all 66 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist with a resident's need for toileting in a timely manner for one (R5) of 18 residents reviewed for resident rights in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise resident Care Plans for two (R17 and R59) of 18 residents reviewed for Care Plans in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician ordered assistive device was used for a resident's contracted hand for one (R36) of one resident reviewed for contractures in a sample of 24.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure for obtaining weights on new admissions for three of three residents (R116, R117 and R366) reviewed for new admissions in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its oxygen policy for changing oxygen equipment and failed to ensure a resident's oxygen humidity bottle was not empty while in use for one resident (R17) of two residents reviewed for oxygen in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a dialysis access site; failed to monitor a dialysis resident's weight per physician order; and failed to ensure communication between the dialysis center and the facility was maintained for one (R116) of one resident reviewed for dialysis in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician ordered medications were administered as ordered for two (R59 and R117) of four residents reviewed for medication administration in the sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene prior to exiting a positive COVID-19 resident room for one (R48) of five residents reviewed for transmission-based precautions in the sample of 24.