Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allure Of Mendota during CMS and state inspections, most recent first.
Delayed Refunds of Resident Funds After Discharge or Death: The facility failed to return resident funds within 30 days after discharge or death for 3 residents. Records and staff interview showed refund checks were delayed for weeks to months, including one case delayed by a Medicare audit and others mailed or received well beyond the required timeframe. The admission contract stated resident funds must be conveyed within 30 days after discharge, eviction, or death.
Unqualified dietary manager performing resident nutritional assessments. The facility failed to ensure the food service director was a CDM for all 64 residents. The Dietary Manager had not completed CDM training, had withdrawn from the class, and was not enrolled in a new class. The Dietary Manager was performing resident nutritional assessments and participating in weekly calls with the dietitian and administrator, while the dietitian stated they did not come into the facility to complete assessments. The facility only had SERV Safe and an expired CFM certificate on file for the Dietary Manager.
A facility failed to provide restorative services to multiple residents with CVA-related paralysis, contractures, and limited mobility. Residents were observed with contracted limbs or supported extremities, and several stated staff were not performing passive ROM exercises; records showed no restorative services documented for these residents, and an ADON said some residents were not receiving restorative care because of budget limits.
Failure to use required PPE and prevent cross-contamination during resident care. Staff entered rooms of residents on RSV contact/droplet isolation without the required gown, mask, face shield, or N95, handled meal trays and spoke with a resident while unprotected, and used soiled gloves during incontinence care and wound care without handwashing or glove changes. A resident with a stage 4 sacral wound and recent wound infection also received wound care after incontinence care was performed with the same soiled gloves.
Incomplete incontinence care was observed for a resident who was frequently incontinent of urine and stool and dependent on staff for care. Two CNAs removed two soaked briefs, but the resident’s front and thigh areas were not cleansed during care; only the buttocks and perineal area were cleaned. The ADON stated double briefs should not be used and that residents should be cleansed thoroughly front and back to prevent infection.
A resident with multiple comorbidities, including dementia and vitamin B deficiency, was found with unexplained bruising on her inner thighs. The facility investigated but did not report the injury of unknown origin to IDPH as required by policy, despite being unable to determine the cause of the bruises.
A resident with multiple comorbidities, including dementia and vitamin B deficiency, was found with unexplained bruising to the inner thighs. The facility did not report the injury to IDPH and failed to conduct a thorough investigation by not interviewing other residents, contrary to facility policy. The investigation was limited to staff interviews, despite the requirement to include all potentially involved persons.
A facility failed to verify a resident's DNR status before initiating CPR, despite the resident's POLST form indicating Do Not Resuscitate. The admitting nurse incorrectly recorded the resident as Full Code, and this misinformation was passed on during shift changes. When the resident was found unresponsive, CPR was started based on incorrect verbal reports, but later stopped when the correct DNR status was confirmed.
A facility failed to provide appropriate care and privacy for a resident with an indwelling urinary catheter. The resident's catheter bag was repeatedly observed without a privacy cover, and the catheter tubing was touching the floor, contrary to facility policy. These issues were confirmed by a CNA and the DON, who acknowledged the catheter bag should have been covered and the tubing should not have been on the floor.
Two residents in an LTC facility experienced medication administration errors, resulting in a 7.69% error rate. An RN administered the wrong dosage of Vitamin D to one resident, while another RN failed to instruct a resident to rinse and spit after using a steroid inhaler, as required by the physician's order.
A resident with a history of medical conditions fell during a transfer using a sit-to-stand lift, but the incident was not reported or documented by the CNAs. The resident experienced ongoing hip pain and was unable to bear weight, yet the facility failed to conduct necessary assessments or communicate the condition to the physician. This resulted in a two-week delay before the resident was sent to the hospital, where a hip fracture was confirmed and surgery was performed.
A resident with multiple medical conditions fell during a mechanical lift transfer due to inadequate handling by CNAs, resulting in a hip fracture. The fall was not reported immediately, and the nurse did not assess the resident before moving her. Delayed medical evaluation led to a late diagnosis of the fracture, requiring surgical repair.
The facility failed to provide sufficient staffing, resulting in long wait times for residents needing assistance with transfers and toileting. Residents with significant medical conditions reported waiting over two hours for help, leading to soiling themselves. CNAs confirmed difficulties in finding coworkers to assist, leading to unsafe practices. The Director of Nurses acknowledged the issue, but the facility lacked a staffing policy, compromising resident dignity and safety.
Two residents were injured during transfers due to the facility's failure to adhere to safety protocols. One resident suffered a hip fracture after a transfer without a gait belt, and another sustained a hip sprain and sacral contusion when a CNA moved a wheelchair without using a gait belt. Both incidents involved non-compliance with the facility's policies on using gait belts and mechanical lifts.
Delayed Refunds of Resident Funds After Discharge or Death
Penalty
Summary
The facility failed to ensure money paid to the facility was refunded to residents or their representatives or estates within 30 days after discharge or death for 3 of 3 residents reviewed for discharge. R1 was admitted to the facility and later expired there; the Business Office Manager stated that a check request was sent to corporate, but the check was delayed because the person processing checks was busy with a Medicare audit. V4 also stated that R1's spouse had to wait for the refund and that the check was not issued until much later, with the refund ultimately provided 98 days after the request process began. The record included check request forms, a check for $6,520.00, and a signature showing the spouse picked up the check. R5 was admitted to the facility and later expired, and the check request for her refund was dated in the record with a check for $4,860.00 issued and mailed to her POA in Arizona 89 days later. R6 was discharged from the facility, and his check request form was sent with a check for $5,940.00 received 68 days later. V4 stated that R6 was a current resident and that the family wanted the money applied to his stay. The facility admission contract stated that upon discharge, eviction, or death, resident funds deposited with the facility must be conveyed within 30 days to the resident or, in the case of death, to the individual or probate jurisdiction administering the estate, in accordance with State law.
Unqualified dietary manager performing resident nutritional assessments
Penalty
Summary
The facility failed to ensure a certified dietary manager was employed as the food service director for all 64 residents in the facility. Record review and interviews showed the Dietary Manager, V13, had not completed the Certified Dietary Manager (CDM) class, had withdrawn from the class in January, and was not currently enrolled in a new class. V13 stated they assisted with resident assessments and participated in a weekly call with the dietitian and administrator. The Administrator stated V13 completed nutritional assessments in-house and discussed resident nutritional concerns during weekly calls. The Dietitian stated they did not come into the facility to complete resident assessments and that V13 performed the assessments. The facility provided certificates showing V13 completed SERV Safe and an expired Certified Food Manager certificate, and ANFP information showed there were no current certified dietary managers in the nation with the same last name as V13. The facility's Dietary Manager Qualifications stated the dietary manager must hold a current Certified Food Protection Manager certificate, should be a CDM or equivalent, and cannot perform nutritional assessments unless qualified by Illinois law.
Failure to Provide Restorative Services for Residents With Contractures and Limited Mobility
Penalty
Summary
The facility failed to provide restorative services to residents with contractures and/or limited mobility for 4 of 6 residents reviewed for mobility and range of motion. R41 had a history of CVA with paralysis to the left arm and left leg, and the care plan and quarterly restorative assessment showed contractures and no documentation of restorative services. When observed, R41 was in bed with a severely contracted left hand in a tight closed fist, with no splint or towel roll noted, and stated staff were not doing passive range of motion exercises to the left arm or left leg. R65 had a CVA with paralysis to the right arm and right leg, and the care plan and quarterly restorative assessment showed limited mobility with no restorative services documented. When observed, R65 was in a wheelchair with the right arm supported on a foam arm rest and stated staff were not doing passive range of motion exercises to the right arm or right leg. R8’s care plan showed diagnoses including acquired absence of right foot toes, osteomyelitis of the right foot, reduced mobility, and difficulty walking, but no documentation of restorative services was present, and the restorative assessment showed limited mobility to the right leg with no restorative services documented. R29 had diagnoses including Alzheimer’s and stroke, with limitation to one side and a contracted right hand in a closed-fist position; no splint was noted. The MDS Coordinator stated the previous restorative nurse had placed R29 on a restorative program that was not being done and there were no follow-throughs or documentation of restorative progress or decline, so the program was discontinued. The ADON stated R41, R65, and R8 were not receiving restorative services because corporate had said only a certain number of people could get restorative services due to the budget, and the facility policy stated restorative nursing services are intended to maintain or improve resident abilities to the highest practicable level.
Failure to Use PPE and Prevent Cross-Contamination During Isolation, Incontinence Care, and Wound Care
Penalty
Summary
The facility failed to ensure required PPE was worn for residents on contact and droplet isolation. R11, R17, and R40 had active physician orders for strict isolation for RSV, and PPE containers with gowns, masks, gloves, and face shields were posted outside their rooms with signs directing staff to use gowns, gloves, eye protection or a face shield, and an N95 mask. On 4/27/26, a CNA entered R17 and R40's room wearing only gloves while delivering meal trays, without applying an N95 mask, face shield, or gown, then continued passing trays in the hallway and entered R11's room again without the required PPE. The Infection Control Nurse stated staff should wear gowns, gloves, N95 masks, and face shields in the rooms of residents on RSV precautions. The facility also failed to prevent cross contamination during incontinence and wound care. R58 tested positive for RSV and was on strict contact and droplet isolation; a CNA entered R58's room without any PPE, spoke with the resident, and handled the breakfast tray with ungloved hands. During incontinence care for R41, a CNA wiped stool, removed the soiled brief, and then placed a clean brief and repositioned the resident without changing soiled gloves, touching bedding and clothing with those gloves. For R5, who had a stage 4 sacral wound and had just completed antibiotic treatment for wound infection/chronic osteomyelitis, a wound nurse provided incontinence care and changed linens with soiled gloves and then performed the wound dressing change without washing hands or changing gloves.
Incomplete Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care in a manner to prevent infection for one resident who was frequently incontinent of stool and urine. During observation on 4/27/26 at 9:15 AM, two CNAs provided incontinent care to the resident and removed two incontinent pads that were both totally soaked with urine. One CNA stated the resident needed two incontinent pads because the facility pads were too thin. The resident was turned to her side, and the CNA used wet washcloths to cleanse the buttocks and perineal area, then the resident was repositioned and a new incontinent pad was applied. The observation showed no cleansing of the resident’s front area and thigh areas during the incontinent care. The resident’s facility assessment documented frequent incontinence of stool and urine, and the care plan stated the resident was incontinent of urine and bowel, wore briefs, and was dependent on staff for incontinence care. The facility’s perineal care policy required cleansing of the perineum from front to back, including the labia and anal area. The ADON stated there should be no double incontinent pads and that residents should be cleansed thoroughly, front and back, to prevent infection.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
The facility failed to report an injury of unknown origin to the Illinois Department of Public Health (IDPH) for a resident who was found with scattered bruising of various colors on her inner thighs. The bruises were first noticed by a CNA during routine care, and the resident, who was a standby assist and sometimes refused care, attributed the bruises to her incontinence briefs. The nurse documented the bruises, and the administrator acknowledged that the cause of the bruises could not be determined, classifying them as injuries of unknown origin. Despite this, the facility did not report the incident to IDPH as required by their own policies and state regulations. The resident involved had multiple diagnoses, including Alzheimer's disease, dementia with behavioral disturbance, diabetes, vitamin B deficiency, and was on palliative care. The administrator later reviewed hospital records and noted that the bruises appeared different over time and that the resident ultimately died after a fall and subsequent hospitalization, with a possible cause of death being an aortic dissection or aneurysm. The facility's policies required investigation and reporting of unexplained injuries, especially those in unusual locations or without a clear cause, but this process was not followed in this case.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for one resident who was found with scattered bruising on her inner thighs. Nursing staff documented the bruising, noting the resident was a standby assist for toileting and sometimes refused care. The resident attributed the bruising to her incontinence briefs, and no pain or discomfort was noted. Despite the presence of unexplained bruising in an unusual location, the facility did not report the incident to the Illinois Department of Public Health (IDPH) as required. The administrator acknowledged that the bruises were investigated only by interviewing staff and not other residents, which was inconsistent with facility policy that requires interviewing all involved persons, including residents, when investigating injuries of unknown origin. The resident involved had multiple diagnoses, including Alzheimer's disease, dementia with behavioral disturbance, diabetes, vitamin B deficiency, and was on hospice care. The administrator reviewed hospital records and noted that the bruising appeared different on subsequent days and that the resident later died, possibly from an aortic dissection or aneurysm, which could explain the bruising. However, the facility's investigation did not include interviews with other residents who might have had relevant information, as required by their own policies on unexplained injuries and abuse investigations.
Failure to Verify Resident's Code Status Before Initiating CPR
Penalty
Summary
The facility failed to verify a resident's code status before initiating CPR, leading to a breach of the resident's rights regarding treatment and advance directives. The resident, who was admitted with a POLST form indicating a Do Not Resuscitate (DNR) status, was mistakenly identified as Full Code by the admitting nurse. This incorrect information was passed on during shift changes, resulting in confusion about the resident's code status when they were found unresponsive. The LPN on duty did not verify the code status in the electronic medical record or the POLST form and initially refrained from starting CPR based on verbal reports. However, CPR was later initiated after a miscommunication about the resident's code status, which was subsequently corrected when the Director of Nursing confirmed the DNR status. The resident's medical history included acute respiratory failure, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart disease, hypertension, and type 2 diabetes mellitus. Despite being alert and oriented upon admission, the resident's code status was inaccurately recorded and communicated among staff. The failure to verify the resident's advance directive and code status led to the initiation of CPR, contrary to the resident's documented wishes. This incident highlights a significant lapse in the facility's adherence to its policies on communicating and respecting residents' advance directives.
Failure to Provide Privacy and Proper Care for Indwelling Catheter
Penalty
Summary
The facility failed to ensure proper care and privacy for a resident with an indwelling urinary catheter. The facility's policy mandates that catheter drainage bags be covered with privacy bags at all times. However, observations revealed that the resident's catheter bag was not covered with a privacy bag on multiple occasions, both in the resident's room and at the dining room table. Additionally, the catheter tubing was observed touching the floor, which is against the facility's policy. These observations were confirmed by a Certified Nursing Assistant and the Director of Nursing, who acknowledged that the catheter bag should have been covered and the tubing should not have been in contact with the floor. The resident had an indwelling urinary catheter due to urinary retention, as documented in the Physician Order Sheet.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and medication instructions for two residents during Medication Administration, resulting in a medication error rate of 7.69%. In the first instance, a Registered Nurse (RN) administered the incorrect dosage of Vitamin D to a resident. The resident's Physician Order Sheet (POS) specified an order for Vitamin D3 oral tablet of 125mcg to be given by mouth in the morning, but the RN mistakenly administered a 25mcg tablet. The RN later confirmed the error, acknowledging that the wrong Vitamin D was pulled from the medication cart. In the second instance, another RN administered an inhaler to a resident without following the proper post-administration procedure. The resident's POS documented an order for Arnuity Ellipta inhalation, which requires the patient to rinse and spit after inhalation to reduce the risk of oropharyngeal candidiasis. However, the RN failed to instruct the resident to rinse and spit after using the inhaler. The RN later confirmed the oversight, acknowledging the failure to follow the prescribed procedure.
Failure to Assess and Communicate Resident's Condition Post-Fall
Penalty
Summary
The facility failed to perform necessary assessments and provide timely treatment for a resident who experienced a fall. The resident, who had a history of multiple medical conditions including a right hip fracture, congestive heart failure, and chronic pain syndrome, fell while being transferred to bed using a sit-to-stand lift. The CNAs involved did not report the fall to the nurse, and as a result, no immediate head-to-toe assessment was conducted. The resident was returned to bed using a total lift without a nurse's evaluation, and the incident was not documented in the progress notes on the day of the fall. The resident continued to experience significant pain in the right hip and was unable to bear weight during therapy sessions. Despite these symptoms, the facility did not conduct ongoing assessments or communicate the resident's condition changes to the physician. The resident's pain persisted for two weeks before being sent to the hospital, where a hip fracture was confirmed, and surgery was performed. The lack of documentation and communication among staff members contributed to the delay in recognizing the severity of the resident's condition. Interviews with facility staff revealed a breakdown in communication and documentation processes. The nurse on duty was unaware of the fall due to the CNAs' failure to report it, and the physical therapy assistant did not document the resident's inability to bear weight or communicate the ongoing pain to the nursing staff. The Director of Nursing acknowledged the lack of documentation and assessments, emphasizing the importance of continued assessments and interdisciplinary communication to ensure proper care and continuity for residents.
Failure in Safe Transfer and Fall Reporting
Penalty
Summary
The facility failed to safely perform a mechanical lift transfer and did not follow their policy and procedure after a fall for one resident, resulting in the resident falling to the floor, sustaining a right hip fracture, and requiring surgical repair. The incident occurred when two CNAs were transferring the resident from a wheelchair to bed using a sit-to-stand lift. The resident, who had multiple medical conditions including right-sided weakness and reduced mobility, was left hanging from the lift by her arms when her legs gave out, and she eventually slipped to the floor. The CNAs involved did not immediately report the fall to the nurse, and the nurse did not perform a head-to-toe assessment before the resident was moved from the floor. The resident complained of pain in her right hip and shoulder, but X-rays were not performed until two days later, and initially, no fracture was detected. It was only after continued complaints of pain and inability to perform activities of daily living that the resident was sent to the hospital, where an MRI revealed a hip fracture requiring surgical intervention. The facility's policies on safe resident handling and fall prevention were not followed, as the fall was not reported immediately, and the necessary assessments and documentation were not completed. The CNAs and the nurse failed to communicate effectively, leading to a delay in the resident receiving appropriate medical evaluation and treatment. The incident highlights a breakdown in the facility's procedures for handling falls and ensuring resident safety.
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple resident interviews and record reviews. The resident roster indicated that 67 residents were residing in the facility. Several residents, including those with significant medical conditions such as right femur fracture, paralysis, urinary tract infection, and chronic kidney disease, reported long wait times for assistance with transfers and toileting. These residents required total staff assistance and were frequently incontinent, yet they experienced delays in call light responses, sometimes waiting over two hours for help, particularly during night shifts. Residents expressed frustration and embarrassment due to the delays, often resulting in them soiling themselves. One resident mentioned being left in bed all day and night due to a lack of staff and necessary equipment like slings. Another resident reported having to transfer themselves to the toilet due to long wait times, which was against facility policy. The issue of insufficient staffing was corroborated by Certified Nurse Aides (CNAs) who reported difficulties in finding coworkers to assist with resident care, leading to unsafe practices such as transferring residents without the required two-person assistance. The Director of Nurses acknowledged the facility's expectation for call lights to be answered within 3-5 minutes and recognized that long response times could indicate a need for more staff. However, the facility was unable to provide any policy related to staffing. The facility's Resident Rights policy emphasized the right to reasonable accommodation of resident needs, which was not being met due to the staffing deficiencies. The lack of adequate staffing compromised the dignity and safety of the residents, as they were unable to receive timely assistance for their basic needs.
Failure to Ensure Safe Resident Transfers
Penalty
Summary
The facility failed to ensure safe resident transfers, resulting in two residents being sent to the hospital due to injuries sustained during transfers. The first resident, R1, who had a history of falls and was at high risk for falls, suffered a left hip fracture after a transfer from the toilet to the sink. The transfer was conducted without the use of a gait belt, contrary to the facility's policy, and the resident's leg gave out, causing her to fall. The CNA involved did not use a mechanical lift to assist the resident after the fall, which was against the facility's no-lift policy. The second resident, R2, also at high risk for falls, experienced a fall during a transfer from a wheelchair to a bed. The CNA did not use a gait belt during the transfer, and while moving the wheelchair, the resident slid off the bed and landed on her left side. This resulted in a left hip sprain and a sacral contusion. The CNA admitted to not using a gait belt and acknowledged that the resident's legs were weak that day, which contributed to the fall. Both incidents highlight a failure to adhere to the facility's policies regarding the use of gait belts and mechanical lifts during resident transfers. The staff involved did not follow the established protocols, which are designed to prevent such accidents and ensure the safety of both residents and staff. These deficiencies in following safety procedures led to significant injuries for both residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mendota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manor Court Of Peru | 14.1 mi | ★★★★★ | 1 | 1 |
| Allure Of Peru | 14.8 mi | ★★★★★ | 3 | 0 |
| Goldwater Care Spring Valley | 15.6 mi | ★★★★★ | 1 | 0 |
| La Salle County Nursing Home | 18.9 mi | ★★★★★ | 0 | 0 |
| Prairie Crossing Lvg & Rehab | 19 mi | ★★★★★ | 10 | 0 |
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