Inspection·September 22, 2022

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete fall that happened (on 9/15/22). The cause of the fall was (V4/CNA) did not use a gait belt during a transfer and (R220) fell. (V4/CNA) was disciplined for her actions. On 9/21/22 at 10:25 A.M., V4/Certified Nursing Assistant stated, I was with (R220) when she fell in her bathroom. I had stood her up to pull her pants up and she lost her balance and fell. I did not use a gait belt, I should have. Event ID: Facility ID: 145151 If continuation sheet Page 2 of 8 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked eight hours a day seven days a week. This has the potential to affect all 67 residents residing in the facility. Residents Affected - Many Findings include: The facility's Direct Care Staffing Requirements Policy and Procedure, revised 1-16-18, documents Policy: (Named facility), owned and managed facilities will meet the staffing needs of the resident population as outlined in Section 300.1220 Supervision of Nursing Services. 1. There shall be at least one registered nurse on duty seven days per week, 8 consecutive hours, in a skilled nursing facility. The facility's Employee Schedules - Weekly, dated 8-28-22 to 9-3-22 and 9-11-22 to 9-17-22, do not have RN coverage on 9-2-22 or 9-16-22. On 9-21-22, at 9:40 am, V6 Certified Nursing Assistant/CNA/Scheduler stated the following: V6 fills in RN (Registered Nurses) coverage with agency RNs. On 9-2-22 and 9-16-22 the RN was (V7) from agency. On 9-21-22, at 10:10am, V2 Director of Nursing/DON stated that V7 is an LPN (Licensed Practical Nurse). V6 stated at this time that V6 was unaware that V7 is an LPN. V2 confirmed that V2 oversees the schedule and RN coverage. V2 stated I overlooked it. The facility's Resident Census and Conditions of Residents, dated 9-19-22, documents 67 residents currently reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 3 of 8 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to develop a comprehensive dementia plan of care for four of five residents (R13, R21, R38 and R64) reviewed for dementia care in the sample of 66. Residents Affected - Some Findings include: The facility's Care Plan Process policy dated 11/2017 documents the following: A comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs, while honoring resident rights to choose. This care plan shall include goals, measurable objectives, and interventions to meet identified resident needs. 1. R21's electronic medical record documents R21 has the following diagnosis: Unspecified Dementia without behavioral disturbance, mood disturbance, anxiety, psychotic disturbance, mood disturbance, Alzheimer's disease, major depressive disorder. R21's current care plan does not document Dementia as a focus area with goals and interventions. On 9/21/2022 at 1:11 PM V2, DON, (Director of Nursing) and V3, ADON (Assistant Director of Nursing) verified R21's care plan does not document Dementia as a focus area with goals and interventions. 2. R13's Physician Order Sheet, dated 9/21/2022, documents, Psychotic Disturbances, Avascular Dementia, Anxiety, and Unspecified Behavioral Syndrome. R13's current Care Plan, dated 9/21/2022, documents, R13 uses an antipsychotic R/T Avascular Dementia. R13's current Care Plan, dated 9/21/2022, does not document the target interventions and specific goals for the diagnosis of Dementia. On 9/21/2022 at 3:30PM V3/ADON (Assistance Director of Nurses), Stated The interventions in the Care Plan for R13 are not specific for the diagnosis Avascular Dementia. 3. R38's Physician Order Sheet dated 9/21/2022, documents, Dementia with Behavioral Disturbances, Hallucinations, Anxiety Disorder, Adjustment Disorder, Unspecified. R38's Care Plan Dated, 9/21/2022 documents, R38 uses an antipsychotic medicine for a diagnosis of Dementia with behavioral disturbances. R38's current Care Plan, dated 9/2022, does not document target interventions and specific goals for the diagnosis of Dementia with Behavioral Disturbances. On 9/21/2022 at 3:30PM V3/ADON (Assistant Director of Nurses), stated, The interventions on R38's careplan are not specific for R38's diagnosis of Dementia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 4 of 8 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0744 Level of Harm - Minimal harm or potential for actual harm 4. R64's current Physician's Order Sheet dated, 9/21/2022, documents, Unspecified Dementia with Behavioral Disturbances, Anxiety, Major Depression. R64's Care Plan dated, 6/23/2022, documents,R64 uses an antipsychotic for the use of Dementia with Behaviors Residents Affected - Some R64's Care Plan dated, 8/29/2022, does not document the target interventions and specific goals for the diagnosis of Dementia. On 9/21/2022 V3/ADON stated, This care plan does not have interventions that are specific for (R64's) diagnosis of Dementia. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 5 of 8 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview and record review, the facility failed to document clinical indications and behaviors to warrant the use of an antipsychotic medication for five of six residents (R13, R18, R21, R38, R64) reviewed for antipsychotic's in the sample of 66. Findings include: The facility's Psychotropic Medication policy dated 11/18/2017 documents the following: Intent: Residents are free from unnecessary psychotropic medication use. Psychotropic medication is any drug that affects the brain activity associated with mental processes and behavior. These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. A) Indications for use for psychotropic medication may include but not limited to 1) Expressions or indications of distress 2) Symptoms are clinically significant that is causing a functional decline 3) Non-pharmacological approaches were implemented and not effective or were clinically contraindicated. Additionally, Antipsychotic medication may be indicated for use if 1) Behavioral symptoms present a danger to the residents or others; 2) Expressions or indications of distress that are significant distress to the resident; 3) If not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presenting a danger or significant distress; and/or 4) GDR (gradual dose reduction) was attempted, but clinical symptoms returned. 1. R18's medical record documents the following diagnoses: Cognitive Communication Deficit, Generalized Anxiety disorder, Major Depressive Disorder, Dementia with Behavioral Disturbances, Psychosis not due to a substance or known physiological condition. R18's Medication Administration Record dated September 2022 documents R18 receives the following medications: Celexa 20 mg (milligrams) in the morning related to Major Depressive Disorder, Risperdal (antipsychotic) 0.5 mg two times a day related to Unspecified Dementia with Behavioral Disturbance, Psychosis not due to a substance or known Physiological condition. R18's current care plan documents the following: Focus-(R18) has the potential for a psychosocial well-being problem related to Anxiety, Dependent behavior, Cognitive Communication Deficit, inability to meet role expectations, pain, repeated accidents/falls, difficulty in walking/generalized muscle weakness, need for assistance for personal care; (R18) has the potential to demonstrate verbally aggressive behaviors, such as yelling at staff, cursing, loud vocalizations related to Dementia, poor impulse control, and tearfulness. (R18) receives antidepressant and antipsychotic medication to help manage her condition. R18's Behavior Symptoms dated 8/23/2022-9/20/2022 document the following behaviors are being monitored: Yelling/screaming, wandering, repeats movement, abusive language. On 9/21/2022 at 1:11 PM V2, DON (Director of Nursing) and V3, ADON (Assistant Director of Nursing) stated R18's diagnosis for the use of Risperdal is depression, with behaviors of agitation, frustration, yelling at staff and in the past she would cry. V2, DON and V3, ADON stated R18 is not a danger (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 6 of 8 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0758 to herself and others. V3, ADON stated this medication is not appropriate, I must have missed this one. Level of Harm - Minimal harm or potential for actual harm 2. R21's electronic medical record documents R21 has the following diagnosis: Unspecified Dementia without behavioral disturbance, mood disturbance, anxiety, psychotic disturbance, Alzheimer's disease, major depressive disorder. Residents Affected - Some R21's Medication Administration Record dated September 2022 documents R21 receives the following medication: Aripiprazole (antipsychotic) 5 mg (milligrams), 1 tablet by mouth at bedtime related to Major Depressive Disorder, Escitalopram Oxalate 5 mg in the morning related to Major Depressive Disorder, Memantine HCL (hydrochloride) 10 mg by mouth two times a day related to Dementia without Behavioral Disturbance, Alzheimer's Disease with late onset. R21's current care plan documents the following: Focus: (R21) uses an antipsychotic for Depression. R21's Behaviors Symptoms record dated 8/23/2022-9/20/2022 document, none of the above observed. On 9/19/2022-9/21/2022 at various times between 9 am and 2 PM R21 was observed in the hallways and her room. R21 was pleasant with no adverse behaviors observed. On 9/19/2022 at 11:49 am R21 denied any concerns and was able to answer questions appropriately with no behaviors displayed. On 9/21/2022 at 1:11 PM V2, DON (Director of Nursing) and V3, ADON (Assistant Director of Nursing) stated R21 was admitted with Aripiprazole for a diagnosis of a history of depression. V2 and V3 stated R21's behaviors are withdrawn and lacks motivation and is not a danger to or self or others. 3. R38's Physician's Order Sheet dated, 9/21/2022, documents Geodon (antipsychotic) 40MG (milligram) twice daily for Psychosis/Delusions and Hallucinations, Buspirone Tablet 10MG (milligrams) for Anxiety, Trazodone Tablet 50MG by mouth at bedtime for insomnia, Melatonin 3MG by mouth at bedtime for sleep, Ativan 0.5MG three times a day for anxiety, and Depakote Sprinkles capsule 125MG twice a day Unspecified Dementia, Hallucinations. R38's Psychiatric Services progress note, dated 6/22/2022, documents, Psychiatric History: Hallucinations. Under assessment documents: Unspecified Dementia with behavioral Disturbances, Adjustment Behavior with Disturbance of conduct, Anxiety disorder, and Hallucinations. R38's Care Plan dated, 4/29/2022, documents, R38 uses antipsychotics medications r/t Dementia with Behavioral Disturbances and Hallucinations. R38's Behavior Tracking Sheet, dated 8/23/2022 - 9/21/2022, documents behaviors being monitored, kicking/hitting, hitting, grabbing, pinching/scratching/spitting, crying, abusive behavior, wandering and, rejection of care. On 9/19/2022 at 11:00AM R38 was observed sitting at the nurses' station sleeping. On 9/20/2022 at 10:30AM during resident care, R38 was calm with no behaviors noted. On 9/21/2022 at 2:30PM V2/DON (Director of Nurses) stated, I understand the behaviors being monitored are not specific for the diagnosis of Psychosis/Delusions, and hallucinations. 4. R13's Physician Order Sheet, dated 9/21/2022, documents the following diagnosis: Anxiety (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 7 of 8 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 145151 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Mendota 1201 First Avenue Mendota, IL 61342 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Disorder, Unspecified Psychosis, Mood Affective Disorder, Major Depressive Disorder and Dementia with Behavioral Disturbances. R13's current Medication Administration Record dated, documents the following medications: Quetiapine Fumarate (antipsychotic) tablet 25MG (milligrams) one tablet by mouth twice a day for Vascular Dementia, Mirtazapine Tablet 15MG one tablet at bedtime (antidepressant) R13's Care Plan, dated 7/12/2022, documents,R13 uses an antipsychotic medication related to depression. R13's Behavior Tracking Sheet, dated 8/24/2022-9/21/2022, documents, None of the above observed. On 9/19/2022 at 1:00PM R13 is observed sitting in R13's room talking with roommate. No behaviors noted. On 9/20/22 at 12 noon R13 was observed eating lunch and talking with the other residents. R13 was in a good mood. On 9/21/2022 at 2:230PM V2/DON (Director of Nurses) stated, I understand the behaviors need to be specific for R13's diagnosis of Vascular Dementia and the behaviors are not targeted behaviors to support the use of an antipsychotic. 5. R64's Physician's Order Sheet, dated 9/21/2022, documents the following diagnosis: Unspecified Dementia with Behavioral Disturbances, Anxiety, Major Depression. R64's Medication Administration Record, dated 9/1/2022-9/30/2022, documents the following medications: Risperdal (Antipsychotic) 0.25MG one by mouth twice a day, Zoloft 150MG in the morning for depression, Clonazepam 0.5MG three times a day for Anxiety. R64's Careplan, dated documents, R64 uses an antipsychotic medication related to Mood Disorder.R64 can become frustrated and use abusive language towards staff. R64's Psychiatric Service progress notes, dated 7/27/2022, documents under assessment: Anxiety Disorder, Unspecified Mood disorder, Major Depressive Disorder. R64's Behavior Tracking Sheet dated 8/24/2022-9/21/2022, documents None of the above was observed. On 9/19/2022 at 12:30PM R64 was observed watching television, no behaviors noted. On 9/21/2022 at 3:30PM V2/DON (Director of Nurses stated, I do understand that there has to be the appropriate behaviors for the antipsychotic medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145151 If continuation sheet Page 8 of 8