Allure of Mendota

In the surveyor’s words

From the most serious findings on record at Allure of Mendota, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 7, 2024

  Based on observation, interview, and record review the facility failed perform assessments, failed to continue to monitor a resident's change of condition, failed to communicate changes in a resident's condition, and failed to provide treatment of a fracture in a timely manner for 1 of 3 residents (R1) reviewed for quality of care in the sample of 7. These failures resulted in experiencing continued pain after a fall on 8/23/24 and a delay in her being sent to the hospital for evaluation and treatment. R1 was transferred to the hospital on 9/5/24 (2 weeks after she fell ) and had surgery for a right hip fracture. The findings include: On 11/6/24 at 10:44 AM, R1 was lying in bed. R1 said there were two CNAs (Certified Nursing Aides) putting her back to bed, after lunch (on 8/23/24). […]

• Actual harm, isolatedF689Nov 7, 2024

  Based on observation, interview, and record review the facility failed to safely perform a mechanical lift transfer and failed to follow their policy and procedure after a fall for 1 of 3 residents (R1) reviewed for safe transfers in the sample of 7. This failure resulted in R1 falling to the floor, sustaining a right hip fracture, and requiring surgical repair of the fracture. The findings include: On 11/6/24 at 10:44 AM, R1 was lying in bed. R1 said there were two CNAs (Certified Nursing Aides) putting her back to bed, after lunch (on 8/23/24). R1 said the wheelchair was parked, facing the bed, near the middle of the bed. R1 said the CNAs applied the sling under her arm, she held onto the grab bar, and they used the lift to stand her up. […]

• Actual harm, isolatedF689Sep 11, 2024

  Based on observation, interview, and record review the facility failed to ensure safe resident transfers for two (R1 and R2) of three residents reviewed for falls with transfers in a sample of three. This failure resulted in R1 and R2 being sent out to the hospital. R1 suffered from pain and a left hip fracture requiring surgery. R2 suffered from pain and a left hip sprain and sacral contusion. Findings include: The facility's undated Safe Resident Handling/Transfers policy documents, Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and… […]

• Actual harm, isolatedF686Oct 20, 2023

  Based on observation, interview and record review, the facility failed to implement pressure ulcer prevention interventions for a resident identified at risk of skin breakdown and failed to complete weekly skin assessments for one of one resident (R8) reviewed for pressure ulcers in the sample of 24. This failure resulted in R8 developing unstageable pressure ulcers to R8's bilateral heels. Findings include: The facility's undated Pressure Injury Prevention and Management Policy documents, Policy - This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. […]

• No harm, potential for more than minimal, widespreadF801Apr 29, 2026

  Based on observation, interview, and record review the facility failed to ensure a certified dietary manager was employed as food service director which applies to all 64 residents in the facility.The findings include:The Centers for Medicare and Medicaid form 671 dated 4/27/26 showed there are 64 residents residing in the facility.On 4/27/26 at 9:00 AM V13 Dietary Manager stated she had not completed the Certified Dietary Manager (CDM) class. V13 stated she was enrolled and had to withdraw in January. V13 stated they were not currently enrolled in a new class. V13 stated they assisted with assessing residents and did a weekly call with V14 Dietitian and V1 Administrator.On 4/27/26 at 11:45 AM, V1 Administrator stated V13 does nutritional assessments in house. […]