Allure of Mt Carroll

In the surveyor’s words

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

• Actual harm, isolatedF692May 22, 2024

  Based on interview and record review the facility failed to implement weight loss prevention interventions prior to a resident (R32) experiencing a significant weight loss. This failure resulted in R32 experiencing a significant weight loss of 9.6% in three months. This failure applies to 1 of 5 residents (R32) reviewed for weight loss in the sample of 14. The findings include: R32's admission care plan dated 12/29/23 showed R32 was at risk for malnutrition and weight loss related to her diagnoses of dementia, dysphagia (trouble swallowing), depression, and a history of pneumonia. R32's Weights and Vitals Summary showed R32's weights as 156 pounds (lbs.) on 2/6/24, 151 lbs. on 3/4/24, 147 lbs. on 4/17/24, and 141 lbs. on 5/3/24. […]

• No harm, potential for more than minimal, widespreadF803Aug 5, 2021

  Based on observation, interview, and record review, the facility failed to follow dietary recipes to ensure the correct serving size was given. This has the potential to affect all residents in the building. The findings include: The facility's census and condition report dated 8/2/21 showed 51 residents in the building. On 8/3/21 at 9:58 AM, the lunch meal was placed on the steam table. There was a #16 two ounce scoop in the mashed and scalloped potatoes. The recipe for mashed potatoes dated 6/29/21 showed, Regular portion: #8 scoop four ounces. The recipe for scalloped potatoes dated 6/17/21 showed, Regular portion: #8 scoop four ounces. On 8/3/21 at 11:20 AM, the lunch meal was being served to residents. […]

• No harm, potential for more than minimal, widespreadF812Aug 5, 2021

  Based on observation, interview, and record review, the facility failed to perform proper cooling procedures, failed to store food in a safe manner, failed to monitor dishwasher sanitizing levels. This has the potential to affect all residents in the building. The findings include: The facility's census and condition report dated 8/4/21 showed 51 residents in the building. 1) On 8/3/21 at 9:40 AM, V5 (Cook) stated, The main entrée for today is pork loin. I cooked it yesterday and put it in the refrigerator overnight. I didn't do a cooling process and we have no cooling logs. On 8/3/21 at 11:28 AM, V5 (Cook) stated, I cooked the pork loin yesterday, took it out of the broth, sliced it and put it in the cooler. We always do meats like that and have never done it differently. […]

• No harm, potential for more than minimal, patternF761Jul 9, 2026

  Based on observation, interview, and record review the facility to store controlled substances in a separately locked, permanently affixed storage container. This applies to 7 of 7 residents (R3, R6, R8, R40, R11, R53, and R57) reviewed for controlled substances in the sample of 33. The findings include:On 7/8/26 at 1:03 PM, the facility's medication room was reviewed with V3 (Assistant Director of Nursing). The door to the room was locked and within the room was a medication refrigerator. In the refrigerator (refrigerator was not locked and had no lock) was a lockbox, which V3 was able to remove from the refrigerator without a key (it was not affixed to the refrigerator). V3 stated the lock box contained lorazepam (an antianxiety mediation) and the refrigerator did not have a lock. […]

• No harm, potential for more than minimal, patternF805May 22, 2024

  Based on observation, interview, and record review the facility failed to provide residents receiving puree diets with smooth consistency to 5 of 5 residents (R15, R6, R18, R20, R25) receiving pureed diets in the sample of 14. The findings include: The Facility provided a document entitled Diet Type Report, dated 5/20/24 show R15, R6, R18, R20, and R25 were receiving pureed textured diet. On 5/20/24 at 11:50 AM, the facility provided a test tray of puree diets that included pureed lasagna, pureed garlic bread, and pureed mixed vegetables. The pureed garlic bread was thick, chunky, and clumpy, and the pureed mixed vegetables was watery, and required chewing. V15 (Dietary Manager) who was with the surveyor during the test tray process also tasted the pureed test tray. […]