Inspection·December 31, 2024

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: The facility's undated Residents' Rights Regarding Treatment and Advance Directives policy documents, Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to staff. The facility's undated Communication of Code Status policy states: It is the facility's policy to adhere to residents' rights to formulate advance directives. In accordance with these rights, the facility will implement procedures to communicate a resident's code status to those individuals who need to know. Designated sections of the medical record are: miscellaneous tab under Advanced Directives. Additional means of communication of code status include: PCC/Point Click Care (the facility's electronic medical record data system) under resident's name is code status. R1's medical record documents R1 was admitted to the facility from the hospital on [DATE] with the following diagnoses: Acute Respiratory Failure with Hypoxia; Chronic Obstructive Pulmonary Disease; Chronic Kidney Disease; Congestive Heart Disease; Hypertension and Diabetes Mellitus Type 2. R1's medical record included a POLST/Physicians Order for Life Sustaining Treatment Form, signed and dated [DATE] by R1 and V16 (R1's Physician). This POLST documented R1's code status was, Do Not Attempt Resuscitation/DNR. R1's Health Status Note by V4 RN/Registered Nurse, dated [DATE] at 3:25pm, documented R1 was admitted by V4 on [DATE] at 3:25pm. V4 documented R1 was alert and oriented, able to answer all questions appropriately. V4 documented R1's code status as Full Code. R1's Health Status Note by V5 LPN/Licensed Practical Nurse, dated [DATE] at 2:25am, documents V5 found R1 unresponsive, pulseless, without respirations, and unable to auscultate an apical pulse. On [DATE] at 1:41pm, V5 LPN stated, during shift change on [DATE], V14/LPN reported that R1's code status was DNR/Do Not Resuscitate. V5 stated he did not check R1's electronic medical record for verification of R1's code status or POLST form at that time. V5 stated when they found R1 unresponsive, pulseless and without respirations, V5 did not start Cardio-Pulmonary Resuscitation/CPR, based on the verbal report V5 received when coming on duty. V5 stated he called V6 RN/Registered Nurse on a (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: 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 12/31/2024 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)