Inspection·November 15, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based 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. Findings include: The facility's undated Catheter Care policy documents, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation: 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. R22's current Physician Order Sheet/POS documents R22 has an indwelling urinary catheter due to urinary retention. On 11/12/24, at 10:23am, R22 sat in his room with no privacy cover on his indwelling urinary catheter bag. On 11/12/24, at 12:40pm, R22 sat at a dining room table with no privacy bag on his indwelling urinary catheter bag and the catheter tubing was touching the floor. On 11/12/24, at 1:07pm, V6 Certified Nursing Assistant/CNA confirmed that R22's indwelling catheter bag is not in a privacy bag and should be covered. V6 also confirmed that R22's catheter tubing was touching the floor and should not be. On 11/13/24, at 8:30am and 11:58am, R22 sat at a dining room table with an indwelling catheter bag hanging underneath his wheelchair. R22's catheter bag did not contain a privacy covering. On 11/14/24, at 1:21pm, V2 Director of Nursing/DON stated that catheter bags are to be covered with privacy covers and catheter tubing should not be touching the floor. 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: 145151 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 11/15/2024 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)