Health inspection·September 23, 2024

F 0684 R1's electronic medical records dated 12/28/23 showed no lab work was drawn or completed on R1 on 12/28/23. R1's electronic medical records showed no labs were drawn on R1 until 1/3/24. Level of Harm - Actual harm R1's Weights and Vitals Summary record showed no documented weight for R1 on 12/28/23. Residents Affected - Few R1's Physician/NP (Nurse Practitioner) progress note dated 12/29/23 showed R1 was seen and examined by V11 NP with V5 (Family of R1) in attendance. The note showed V11 NP found R1 to have mild edema to her feet and ankles. The note showed V5 (Family of R1) was very concerned about R1's lower leg swelling. V11 NP explained to (V5) that if the edema starts to creep up the leg, (R1) becomes increasingly short of breath, confused, etc., that this would be of concern . R1's nurses note dated 12/29/23 showed R1's oxygen saturation levels had decreased while on supplemental oxygen. The note showed R1 required an albuterol inhaler treatment and a brief increase in oxygen, from 3 liters to 5 liters via nasal cannula, to maintain R1's oxygen saturation levels within the prescribed parameters. R1's skilled evaluation nurses note dated 12/30/23 showed R1's weight had increased to 155.6 lbs on 12/29/23. The note showed the edema (swelling) to R1's lower extremities had increased (worsened) to +3 pitting edema. R1's Weights and Vitals Summary record showed no documented weights for R1 on 12/30/23 or 12/31/23. The summary showed R1 weighed 154.5 lbs on 1/1/24. R1's nurses note dated 1/2/24 showed R1 continued to have pitting edema to her bilateral lower extremities. R1's nurses note dated 1/3/24 showed staff found R1 to be more confused, with low oxygen saturation levels. The note showed R1 had lung crackles present with +3 pitting edema bilaterally to R1's lower extremities. R1 was sent emergently, via ambulance, to a local hospital for an evaluation. R1's hospital records dated 1/3/24 showed R1 was readmitted to the hospital due to an exacerbation of congestive heart failure. The hospital records showed R1 was brought back to the hospital due to increased confusion and was found to be fluid overloaded. On 9/18/24 at 1:35 PM, V11 NP stated weights should be obtained and monitored on residents with congestive heart failure because if the resident is putting on too much fluid, their condition could spiral into CHF and the resident could wind up back in the hospital. V11 stated, (R1's) weight really needed to be monitored due to her edema (to her lower extremities). V11 NP stated she noted R1 had mild edema to her lower extremities on 12/29/23. On 9/23/24 at 9:41 AM, V4 (R1's Physician) stated he ordered lab work on R1 on 12/28/23 to check her kidney function and electrolyte status. V4 stated no lab work was done on R1 on 12/28/23. V4 stated R1 had no lab work drawn, in the facility until 1/3/24, just prior to her being sent back to the hospital for a change in condition. V4 stated he ordered daily weights to be done on R1, starting 12/28/23, because R1 was becoming more edematous. When I saw her on December 21st (2023), she had no edema to her lower extremities. V4 stated, Labs and weights are to be done on residents as ordered. Residents, such as (R1), with CHF and/or kidney failure need to be monitored closely because if their kidneys worsen or CHF worsens, the resident can become more edematous. I (V4) monitor residents with CHF by examining them along with monitoring their weights and labs. If residents aren't weighed as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 2 of 3 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 09/23/2024 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few ordered or labs aren't done, it can impede the way I (V4) medically manage the resident. If a resident is becoming more edematous and weights and labs are not done as ordered, that resident's health could deteriorate . On 9/23/24 at 10:36 AM, V3 Assistant Director of Nursing stated all residents should be weighed up admission and readmission to the facility to verify the accuracy of a resident's weight. V3 stated nursing is responsible for ensuring residents are weighed and lab work is completed, as per physician order. V3 stated the admitting nurse is responsible for reviewing all resident's hospital discharge instructions and physician orders to ensure these orders are put into place. The Director of Nursing (DON) would then double check the admitting orders to make sure nothing was overlooked. On 9/23/24 at 10:45 AM, V1 Administrator stated she didn't know why R1's weights and labs were not done as per physician order. V1 stated, (V12 Former DON) was overseeing the weights and labs for (R1) at that time. I (V1) don't know why they weren't done. V1 stated V12 (Former DON) no longer worked at the facility. On 9/23/24, this surveyor made two attempts to contact V12 (Former DON) via phone for an interview but was unsuccessful. The facility's Provision of Physician Ordered Services policy dated 12/1/23 showed, The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders . Qualified personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity . 2. R5's admission Record dated 7/5/24 showed R5 was admitted to the facility with diagnosis of congestive heart failure (CHF). A physician order dated 8/7/24 for R5 showed for R5 to be weighed daily. The order showed staff were to report to R5's physician if R5 gained 3 lbs or more in one day or 5 lbs or more in one week. R5's Weight and Vitals Summary dated August 2024 and September 2024 showed no documented weights for R5 on 8/7/24-8/8/24, 8/15/24-8/17/24, 8/20/24-8/22/24, 8/25/24-8/27/24, 9/3/24, 9/7/24, or 9/8/24. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145024 If continuation sheet Page 3 of 3