Inspection·September 16, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review the facility failed to ensure residents were treated in a dignified manner. This applies to 2 of 13 residents (R12 & R14) reviewed for dignity in the sample of 13. Residents Affected - Few The findings include: 1. On September 16, 2024, at 1:44 PM, R12 stated, V12 Certified Nursing Assistant (CNA) was short with residents. She has gotten to a point where she doesn't want to ask V12 CNA for anything, she does it herself if she can or will wait for someone else. On September 16, 2024, at 2:47 PM, R14 stated, V12 CNA walked into her room one day without knocking. R14 asked V12 CNA, do you let people walk into your room without knocking? V12 CNA responded, I'm not going to talk about that and walked out of R14's room. V12 CNA then refused to help her. On September 16, 2024, at 9:10 AM, V16 CNA stated, V12 CNA is very rude and always yelling at people. On September 16, 2024, at 9:42 AM, V3 CNA stated, V12 CNA has an attitude problem. On September 16, 2024, at 1:14 PM, V2 Assistant Director of Nursing (ADON) stated, V12 CNA has had lots of complaints about her attitude. Residents complain about how she talks to them and treats them. R12 told her that she doesn't ask V12 CNA for anything. V2 ADON stated, if R12 feels like she can't ask staff for things she needs that is a problem. 2. On September 16, 2024, at 3:53 PM, V7 CNA was sitting at the nursing station on her cell phone. On September 16, 2024, at 2:47 PM, R14 stated, staff are always on their phones. I don't think that's right. On September 16, 2024, at 3:25 PM, V1 Administrator stated, staff are not supposed to be on their cell phones. The facility's promoting/maintaining resident dignity dated December 1, 2023, shows, Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: .10. Speak respectfully to residents; avoid discussions about residents that may be (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145024 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145024 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Pinecrest 414 South Wesley Avenue Mount Morris, IL 61054 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)