Health inspection·May 7, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an injury of unknown origin to Illinois Department of Public Health (IDPH) for a resident with bruises to her inner thigh area for 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 6. The findings include: The Nurses Note dated [DATE] at 12:01 AM for R1 showed, the aides took the resident to the bathroom and had noticed scattered bruising to her inner thighs (yellow, green, and purple bruises). The certified nursing assistant (CNA) stated they were not sure how long they have been there due to resident being a standby assist and taking herself to the bathroom. Resident also refuses cares at times. When I asked the resident stated, it's from these and pointed to her depends. No pain or discomfort noted to the area of bruising. The facility did not report the bruises to R1's inner thighs to Illinois Department of Public Health (IDPH). On [DATE] at 10:11 AM, V1 (Administrator) stated, injuries of unknown origin could be bruises and if they can't find a reason or a conclusion as to how the bruises happened then she would investigate the bruises as an injury of unknown origin. V1 stated R1 had a bruise to her left thigh and a small mark to her right thigh. On Thursday ([DATE]) morning the nurse documented that R1 had bruises to her thighs. V1 stated they investigated the bruises and R1 would bump into things. V1 stated they thought that R1 would bump into the foot board of her bed when she was trying to get snacks that were located on a credenza at the end of her bed. V1 stated the bruises were to R1's inner thigh area on the left and a small one to inner thigh on the right. On Friday ([DATE]) night R1 fell; she was on hospice. R1 didn't break her fall, was sent to the hospital, and came back on Saturday ([DATE]) with a diagnosis of a urinary tract infection (UTI). V1 stated that same day R1 complained of chest pain; she was restless and was acting out. Hospice was contacted and they said to send her to the hospital. V1 stated she pulled up the pictures that the hospital had in R1's chart of the bruises to her inner thigh and they did not look the same as what she saw when she observed R1's bruises. They looked different from Thursday to Friday ([DATE]). When R1 went back to the hospital on Saturday ([DATE]) they got her up to the commode, she stood up, collapsed, they put her in bed, and she died. V1 stated she looked at the hospital records and the doctor documented that she possibly died from an aortic dissection or aortic aneurysm, and this would explain the bruising. She also did have low vitamin B level and bruised easily. On [DATE] at 1:14 PM, V1 stated an injury of unknown origin is an injury that can't be explained as Page 1 of 4 145151 145151 05/07/2025 Allure of Mendota 1201 First Avenue Mendota, IL 61342

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few far as the cause or there are no witnesses to the injury. A bruise that shows up that can't be explained would be investigated. V1 confirmed if a bruise were in an unusual place they would investigate it as injury of unknown origin. V1 stated she should have reported to IDPH. The Face Sheet dated [DATE] for R1 showed diagnoses including Alzheimer's disease, palliative care, dementia with behavioral disturbance, type 2 diabetes mellitus, acute cystitis without hematuria, deficiency of B vitamins, hypomagnesemia, unspecified behavioral syndromes, anxiety disorder, and essential hypertension. The facility's Unexplained Injuries policy ([DATE]) showed, all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated. An injury should be classified as an injury of unknown source when both of the following conditions are met: A, the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of i. The extent of the injury or ii. The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) Reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures. The facility's Abuse, Neglect, and Exploitation policy (2025) showed, possible indicators f abuse include, but are not limited to: physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. Physical injury of a resident, of unknown source. Reporting of all alleged violations to the Administrator, state agency, adult protective services and other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 145151 Page 2 of 4 145151 05/07/2025 Allure of Mendota 1201 First Avenue Mendota, IL 61342

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a thorough investigation was done by interviewing additional residents when a resident had an injury of unknown origin that consisted of bruising to her inner thighs for 1 of 3 residents (R1) reviewed for injury of unknown origin in the sample of 6. Residents Affected - Few The findings include: The Nurses Note dated [DATE] at 12:01 AM for R1 showed, the aides took the resident to the bathroom and had noticed scattered bruising to her inner thighs (yellow, green, and purple bruises). The certified nursing assistant (CNA) stated they were not sure how long they have been there due to resident being a standby assist and taking herself to the bathroom. Resident also refuses cares at times. When I asked the resident stated, it's from these and pointed to her depends. No pain or discomfort noted to the area of bruising. The facility did not report the bruises to R1's inner thighs to Illinois Department of Public Health (IDPH). On [DATE] at 10:11 AM, V1 (Administrator) stated, injuries of unknown origin could be bruises and if they can't find a reason or a conclusion as to how the bruises happened then she would investigate the bruises as an injury of unknown origin. V1 stated R1 had a bruise to her left thigh and a small mark to her right thigh. On Thursday ([DATE]) morning the nurse documented that R1 had bruises to her thighs. V1 stated they investigated the bruises and R1 would bump into things. V1 stated they thought that R1 would bump into the foot board of her bed when she was trying to get snacks that were located on a credenza at the end of her bed. V1 stated the bruises were to R1's inner thigh area on the left and a small one to inner thigh on the right. On Friday ([DATE]) night R1 fell; she was on hospice. R1 didn't break her fall, was sent to the hospital, and came back on Saturday ([DATE]) with a diagnosis of a urinary tract infection (UTI). V1 stated that same day R1 complained of chest pain; she was restless and was acting out. Hospice was contacted and they said to send her to the hospital. V1 stated she pulled up the pictures that the hospital had in R1's chart of the bruises to her inner thigh and they did not look the same as what she saw when she observed R1's bruises. They looked different from Thursday to Friday ([DATE]). When R1 went back to the hospital on Saturday ([DATE]) they got her up to the commode, she stood up, collapsed, they put her in bed, and she died. V1 stated she looked at the hospital records and the doctor documented that she possibly died from an aortic dissection or aortic aneurysm, and this would explain the bruising. She also did have low vitamin B level and bruised easily. On [DATE] at 1:14 PM, V1 stated an injury of unknown origin is an injury that can't be explained as far as the cause or there are no witnesses to the injury. A bruise that shows up that can't be explained would be investigated. V1 confirmed if a bruise were in an unusual place they would investigate it as injury of unknown origin. V1 stated residents were not interviewed as part of their investigation and should have been. V1 stated they only interviewed staff. The Face Sheet dated [DATE] for R1 showed diagnoses including Alzheimer's disease, palliative care, dementia with behavioral disturbance, type 2 diabetes mellitus, acute cystitis without hematuria, deficiency of B vitamins, hypomagnesemia, unspecified behavioral syndromes, anxiety disorder, and essential hypertension. 145151 Page 3 of 4 145151 05/07/2025 Allure of Mendota 1201 First Avenue Mendota, IL 61342

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's Unexplained Injuries policy ([DATE]) showed, all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated. An injury should be classified as an injury of unknown source when both of the following conditions are met: A, the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of i. The extent of the injury or ii. The location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) Reporting and investigation procedures shall be implemented in accordance with the facility's abuse policies and procedures. The facility's Abuse, Neglect, and Exploitation policy (2025) showed, possible indicators f abuse include, but are not limited to: physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. Physical injury of a resident, of unknown source. Investigation of alleged abuse, neglect, and exploitation - an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who may have knowledge of the allegations. 145151 Page 4 of 4