Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allure Of Mt Carroll during CMS and state inspections, most recent first.
A resident experienced a significant weight loss of 9.6% over three months due to the facility's failure to implement weight loss prevention interventions. Despite being identified as at risk for malnutrition and weight loss, no supplements or supervised dining were initiated in a timely manner, leading to the resident's significant weight loss.
The facility failed to provide residents on pureed diets with food of smooth consistency. Observations revealed that the pureed garlic bread was thick and clumpy, while the pureed mixed vegetables were watery and required chewing. The Dietary Manager confirmed these issues, noting that the foods did not meet the facility's policy for pureed food preparation.
A facility failed to obtain a physician's order, consent, and perform an assessment for a resident using a seat belt in a motorized wheelchair. The resident had been using the seat belt since admission without proper documentation and assessment, which was only initiated on the day of observation. The DON confirmed the oversight, and the facility's policy on restraint use was not followed.
The facility failed to reassess a resident for safe swallowing after a choking episode, left a resident with a history of falls unsupervised on the toilet, and did not use a gait belt during a transfer, leading to a fall. These deficiencies highlight lapses in resident safety and supervision.
The facility failed to perform perineal care properly, using the same wet wipe multiple times to clean a resident with multiple diagnoses, contrary to the facility's policy. Interviews confirmed that proper procedures were not followed, increasing the risk of infection.
A facility failed to measure the external length of a PICC line for a resident receiving IV antibiotics for osteomyelitis, despite performing weekly dressing changes. The Director of Nursing confirmed the necessity of these measurements, but no documentation was found in the Treatment Administration Record.
The facility failed to perform proper hand hygiene and change gloves to prevent cross-contamination during incontinence care for a resident with multiple diagnoses. A CNA did not change gloves or perform hand hygiene after touching the resident's body and stool, contrary to the facility's hand hygiene policy.
The facility failed to protect residents' money, resulting in $160 and $33 missing from two residents' rooms. The money was not recovered, and a staff member was suspected but had been terminated for an unrelated reason. The facility's policy on abuse and misappropriation was reviewed.
The facility failed to contact law enforcement in a timely manner when two residents reported missing funds. One resident reported $160 missing, and another reported $33 missing. Despite these reports, the facility did not contact the local police until several days later, contrary to the facility's Abuse Policy, which requires immediate reporting.
Failure to Implement Weight Loss Prevention Interventions
Penalty
Summary
The facility failed to implement weight loss prevention interventions for a resident (R32) who experienced a significant weight loss of 9.6% over three months. R32 was at risk for malnutrition and weight loss due to diagnoses of dementia, dysphagia, depression, and a history of pneumonia. Despite being identified as at risk for weight loss in a Mini Nutritional Assessment completed remotely by the Registered Dietician (V3) in April 2024, no weight loss preventions such as supplements or supervised dining were initiated at that time. R32's weight dropped from 156 lbs. on 2/6/24 to 141 lbs. on 5/3/24, showing a significant weight loss that was not addressed promptly by the facility's staff. The Registered Dietician (V3) admitted that she had last assessed R32 in person in January 2024 and completed the April 2024 assessment remotely by reviewing information via the computer. V3 acknowledged that the facility monitors residents' weight loss weekly to intervene before it becomes significant but failed to provide a satisfactory explanation for not starting weight loss supplements and supervised dining sooner. The facility's policies on Nutrition at Risk and Weight Monitoring emphasize the importance of early identification of risk factors and timely intervention, which were not adhered to in this case, leading to R32's significant weight loss.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
The facility failed to provide residents receiving pureed diets with food of smooth consistency, as required. During a test tray observation, the pureed garlic bread was found to be thick, chunky, and clumpy, while the pureed mixed vegetables were watery and required chewing. The Dietary Manager confirmed these observations, noting that the pureed garlic bread needed more liquid to achieve the correct texture and that the pureed mixed vegetables needed to be smoother. The facility's policy on pureed food preparation specifies that pureed foods should be smooth and similar to a thick pudding or soft mashed potato consistency. However, the observed pureed foods did not meet these standards, affecting five residents on pureed diets.
Failure to Obtain Physician's Order and Consent for Seat Belt Use
Penalty
Summary
The facility failed to obtain a physician's order, consent, and perform an assessment for a resident using a seat belt in a motorized wheelchair. The resident, who was admitted with multiple diagnoses including muscle weakness, contractures, tracheostomy status, hemiplegia, malnutrition, anxiety disorder, and contracture to her left hand, was observed using a seat belt to prevent sliding out of the chair. The consent for the self-releasing seat belt was signed on the same day it was observed, and the care plan and order for the seat belt were also initiated on that day, indicating a lack of prior documentation and assessment for the restraint use. The Director of Nursing confirmed that the resident had been using the seat belt since admission and acknowledged that there should have been a doctor's order, consent, and quarterly assessments. The facility's policy on a restraint-free environment requires that residents may use devices for positioning and safety purposes with a signed consent and that the facility is responsible for evaluating the appropriateness of the request, explaining potential risks and benefits, and considering alternatives to restraint use. These steps were not followed prior to the observation date, leading to the deficiency.
Failure to Ensure Resident Safety and Proper Supervision
Penalty
Summary
The facility failed to reassess a resident for safe swallowing after a choking episode. The resident, diagnosed with Parkinson's Disease, dementia, and cognitive impairment, experienced a choking incident while taking evening medications. Despite the choking episode, the resident continued to receive medications whole, and no referral to speech therapy or changes in diet were made. The facility's Director of Nursing acknowledged the oversight, stating that the necessary steps were not taken due to being busy. Another deficiency involved a resident with a history of falls who was left unsupervised on the toilet. The resident, diagnosed with dementia and weakness, required partial to moderate assistance for toileting and transfers. Despite this, the resident was left alone in the bathroom, and when staff did assist, they did not use a gait belt for the transfer, which is against the facility's policy. A third deficiency was noted when a resident with weakness and a history of falls was not safely transferred by staff. The resident fell while being assisted to a scale without the use of a gait belt. The CNA assisting the resident admitted to not using a gait belt and not holding onto the resident during the transfer, leading to the fall. The facility's policy mandates the use of gait belts for residents who cannot independently ambulate or transfer.
Improper Perineal Care Leading to Infection Risk
Penalty
Summary
The facility failed to perform perineal care in a manner that prevents urinary tract infections for one resident. The resident, who has multiple diagnoses including dementia, influenza, pneumonia, and muscle wasting, was observed to have her incontinence brief changed by two CNAs. During the process, the CNAs used the same wet wipe multiple times to clean a large amount of stool from the resident's buttocks and peri area, contrary to the facility's policy which requires the use of a new wipe if the perineum is grossly soiled. Interviews with staff revealed that the CNAs did not follow the proper procedure for perineal care. One CNA stated that a new wet wipe should be used if stool is noted, while the Director of Nursing confirmed that a new wipe should be used when there is a large amount of stool to prevent the spread of infection. The facility's Perineal Care policy also supports this practice, emphasizing the importance of using separate wipes to maintain cleanliness and prevent infection.
Failure to Measure PICC Line Length
Penalty
Summary
The facility failed to measure the external length of a peripherally inserted central catheter (PICC) for a resident who required intravenous (IV) antibiotics for osteomyelitis. The resident, who had a PICC line placed as per hospital discharge instructions, reported that the facility had been performing weekly dressing changes but had not been measuring the external length of the PICC. The Director of Nursing confirmed that PICC measurements are necessary to check for migration and should be documented in the Treatment Administration Record (TAR). However, a review of the resident's TAR showed no documented PICC measurements during the dressing changes on three separate occasions, despite the facility's policy requiring such measurements.
Failure to Perform Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to perform proper hand hygiene and change gloves to prevent cross-contamination during incontinence care for a resident diagnosed with dementia, influenza, pneumonia, psychotic disorder, muscle wasting, obesity, fluid overload, weakness, and a history of falling. On May 20, 2024, two CNAs provided incontinence care for the resident, whose brief was saturated with urine and a large amount of stool. One CNA did not change gloves or perform hand hygiene after touching the resident's body and stool, leading to potential cross-contamination. The facility's hand hygiene policy mandates proper hand hygiene procedures to prevent the spread of infection, which was not followed in this instance.
Failure to Protect Residents' Money
Penalty
Summary
The facility failed to protect residents' money from being taken from their rooms, affecting two residents. The facility's Final Incident Report confirmed that Resident 1 had at least $160 and Resident 2 had $33 missing from their rooms. The money was not recovered during the investigation. The Administrator stated that the incidents were reported on consecutive days, and a staff member was suspected but had been terminated for an unrelated reason. Resident 1 reported that she had taken $200 out of her bank account and spent $40 on toiletries before being admitted to the facility. She kept the remaining money in a bank envelope in her nightstand, which was found empty when she attempted to retrieve money for a family member. Resident 2 reported that she kept her money in a resealable bag within her room, and upon checking, found the money missing and the bag disorganized. The facility's Abuse Policy defines misappropriation as the wrongful use of a resident's belongings or money without consent. On 5/1/24, the Administrator confirmed that Resident 1's family verified the missing $160, and Resident 2's family confirmed the missing $33. The investigation concluded that both residents had money removed from their rooms. Resident 1 stated that she had not accessed the money since being admitted to the facility, and Resident 2 noticed the disorganization of her bag after hearing about the missing money. The facility suspected a Certified Nursing Assistant, who was terminated on an unrelated matter, but the money was not recovered. The facility's policy on abuse and misappropriation was reviewed, highlighting the failure to protect residents' belongings as required.
Failure to Timely Report Misappropriation of Funds
Penalty
Summary
The facility failed to contact law enforcement in a timely manner when allegations of misappropriation of funds were reported by two residents. On 4/23/24, one resident reported approximately $160 missing, and on 4/24/24, another resident reported $33 missing. Despite these reports, the facility did not contact the local police until 5/1/24. The facility's Administrator confirmed that law enforcement was not contacted at the time of the allegations. The facility's Abuse Policy, dated 2/1/24, mandates that all alleged violations be reported to the Administrator, state agency, adult protective services, and other required agencies, including law enforcement, within specified timeframes, which include immediately, but no later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 119 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mount Carroll
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Big Meadows | 7.9 mi | ★★★★★ | 5 | 0 |
| Allure Of Stockton | 16.5 mi | ★★★★★ | 0 | 0 |
| Manor Court Of Freeport | 17.6 mi | ★★★★★ | 31 | 0 |
| Eagle Point Nursing And Rehabilitation | 19.2 mi | ★★★★★ | 7 | 0 |
| Serenity Estates Of Lena | 19.7 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Allure Of Mt Carroll.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.