Inspection·December 12, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 document resident assessments for 2 of 3 residents (R4, R7) reviewed for change of condition in the sample of 13. Residents Affected - Few The findings include: 1. R4's face sheet documents she was admitted to the facility on [DATE] and discharged on [DATE]. R4 had multiple diagnoses including chronic respiratory failure, oxygen dependency, and COPD (chronic obstructive pulmonary disease). The order summary sheet shows an order for oxygen at 2L (liters) continuous. R4 had an order for a full code status. On [DATE] at 8:50 AM, V1 (Administrator) documented during the AM medication pass, nurse entered (R4's) room to observe resident with no pulse and no respirations. Code blue called. This writer assessed resident and CPR (Cardiopulmonary Resuscitation) initiated at 7:50 AM. 911 called and CPR continued until EMS arrived. Resident left facility, with no pulse/respirations at 8:34 AM with [NAME] Machine (chest compression machine) operating. The progress notes did not contain any assessment or description of R4 at the time of the code, including where she was, physical appearance or if any vitals were able to be obtained. On [DATE] at 10:30 AM, V16 LPN (Licensed Practical Nurse) said on [DATE] she was the day shift nurse assigned R4, on the garden unit. V16 said at the time of the incident, she was on the 200 wing passing medications when her aide from gardens came running to get her for a non-responsive resident. V16 said she ran to the garden unit, verified R4's code status to be a full code and initiated CPR. V16 said R4 had bubbles around her mouth and nose, and her oxygen cannula was still in her nose. V16 said multiple staff began to appear and assist with the code by calling 911, family and the physician. V16 said R4 left the facility with the ambulance crew continuing CPR. After R4 left, V1 instructed her to write down the last set of vital signs. V16 said as a new nurse she was not sure what to do or what needed to be done as far as documenting anything. V16 said she dropped the ball and should have documented how R4 was found, and step by step details of events and the time they occurred. On [DATE] at 11:10 AM, V2 DON (Director of Nursing) said following an incident such as a code blue, the nurse should be documenting when the resident was last seen, how they found the resident, their color, the temperature of their skin whether they are cold or still warm to touch, if there are any vital signs or no vital signs. The progress notes should note when CPR began, and when paramedics arrived, and when the resident left or expired. The notes should also contain what staff were present for the code. (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: 145615 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 145615 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Sterling 612 West St Mary's Street Sterling, IL 61081 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)