Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Controlled substances were not stored in a separately locked, permanently affixed container. During med room observation, an unlocked medication refrigerator contained a removable lockbox with lorazepam inside, and the ADON was able to remove it without a key. The DON stated controlled substances need to be double locked, while the Corporate Nurse stated the refrigerator is typically the separately locked storage for controlled substances. Seven residents were identified as receiving lorazepam.
A resident's right to private space was not protected when another resident who wandered the halls repeatedly entered his room and went through his dresser and closet. The resident said this had happened before, was upsetting, and had been reported to staff; he also stated he could be startled when awakened by the other resident in his room. The care plan noted concerns about peers entering the room, and interviews showed conflicting staff awareness of the wandering resident's access to the area.
The facility failed to document a resident's transfer to the hospital and failed to issue a bed hold. The resident, who had a cerebral infarction with L-sided paralysis, left for an outpatient procedure, was found to have a UTI, and was admitted for IV antibiotics before the procedure. Staff stated the transfer details and bed hold should have been documented.
Failure to provide requested grooming assistance: A resident with ADL self-care deficits, macular degeneration, weakness, COPD, CHF, and an absent LUE below the elbow was observed with thick facial stubble and stated he wanted to be shaved but could no longer shave himself because of poor eyesight. Staff stated male residents are usually shaved daily or based on preference, yet the resident reported it had been a few days since he had been shaved.
Failure to Ensure Continuous Oxygen Availability: A resident with multiple chronic conditions, including CHF and lung disorders, was observed short of breath with a RR of 30 while her nasal cannula was connected to an empty portable O2 tank. Staff had not changed her from the portable tank back to the room concentrator after an appointment, and the RN confirmed the tank was empty before switching her to the concentrator at 2 L NC as ordered.
Puree Diet Menu Not Followed: The facility failed to follow the posted menu for residents on a puree diet. A cook pureed only two menu items for the noon meal and did not puree the dessert, instead serving applesauce to a resident. The DON/DM stated all menu items, including desserts, should be pureed, and a resident on a puree diet said she usually received applesauce, pudding, or ice cream for dessert.
Puree diets were not prepared according to the recipe for 3 residents. A cook pureed Swiss steak, then added cold milk instead of the required hot beef broth, and the reheated temperature was only 148 degrees instead of the expected 165 degrees. The dietary manager stated the cook should have followed the recipe for puree foods.
A facility failed to have visible EBP signage for three residents who required precautions due to a trach, dialysis, and bilateral leg wounds. The ADON/IP stated the signs should be posted so staff and visitors would know the precautions required, but one sign was hidden behind a PPE bin and the others were not visible. During wound care for one resident, supplies were placed on a soiled disposable pad, and the ADON acknowledged the infection control issue.
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.
Controlled Substances Not Stored in Properly Locked Container
Penalty
Summary
Controlled substances were not stored in a separately locked, permanently affixed storage container. During observation of the medication room with the ADON, the medication refrigerator was unlocked and had no lock, and a lockbox containing lorazepam was inside the refrigerator. The lockbox could be removed from the refrigerator without a key because it was not affixed to the refrigerator. The ADON stated the lockbox contained lorazepam and that the refrigerator did not have a lock. During interview, the DON stated narcotics and lorazepam need to be locked due to the increased risk of drug diversion and that controlled substances need to be double locked, although she believed the medication room door served as the permanently affixed lock. The Corporate Nurse stated the refrigerator is typically also locked and would be considered the separately locked and permanently affixed storage for controlled substances, and that the lorazepam box should not have been removable from the refrigerator without unlocking the refrigerator or having the box secured to it. A resident list provided by the DON identified seven residents receiving lorazepam: R3, R6, R8, R40, R11, R53, and R57. The facility policy stated controlled substances are to be safeguarded and stored in a substantially constructed storage unit with two locks.
Resident's private space was not protected from peer entry
Penalty
Summary
The facility failed to protect a resident's right to a dignified existence and private space for 1 of 1 residents reviewed for resident rights. R41 stated that another resident, R5, who wanders the halls in a wheelchair, had entered his room and gone through his dresser and closet, with the last occurrence reported by R41 as happening 4 days earlier. R41 said this had happened before and that he had reported it. He also stated that when he falls asleep he sometimes feels someone looking at him and finds R5 in his room, which he described as upsetting. R41 reported a history of being jumped and mugged when younger, resulting in loss of eyesight in one eye, and said that when someone gets close to him it puts him in a defensive mood. R41's care plan dated 5/14/26 documented concerns about peers entering his room and included a request for a stop plastic strip to deter entry, along with education on safety and use of a stop sign, nurse identification of the area of concern, and notification of the appropriate department leader and Social Services. The resident's face sheet listed diagnoses including left eye blindness, obesity, hypothyroidism, urinary tract infection, gastrointestinal hemorrhage, COPD, aneurysm of the thoracic aorta, obstructive and reflux uropathy, and necrotizing fasciitis. The MDS showed no cognitive impairment. During interviews, the Social Service Director stated R41 had been moved to another hall and no longer had the stop sign across his doorway, while a CNA stated that R5 still wanders down the hall to the end and goes into other resident rooms. R41 stated he had told CNAs about R5 entering his room, and the SSD confirmed it was R41's right and choice not to have R5 in his room.
Failure to Document Hospital Discharge and Issue Bed Hold
Penalty
Summary
The facility failed to document a resident's discharge to the hospital and failed to issue a bed hold for one resident reviewed for discharge. The resident was admitted following a cerebral infarction with left side paralysis. Her census record showed she was discharged to the hospital and later returned to the facility, but her progress notes for the discharge date contained no documentation of her transfer out of the facility or any notes regarding the hospital discharge. A registered nurse stated the resident was going back to the hospital for a procedure, was found to have a urinary infection, and was admitted for IV antibiotics, and said the notes should show how she left, where she went, and that a bed hold should be issued. The DON stated the resident left for an outpatient appointment in the facility van, was then admitted to the hospital for treatment before the procedure, and that all of this should have been documented and a bed hold issued once she was admitted.
Failure to Provide Requested Grooming Assistance
Penalty
Summary
The facility failed to ensure a resident’s facial hair was shaved for 1 of 1 resident reviewed for activities of daily living. During observation, the resident was sitting in his wheelchair in his room and had thick facial stubble. He stated he would like to be shaved and reported that at home he shaved himself every day, but he could no longer do so because of his eyesight. He also stated it had been a few days since staff had shaved him. Interview and record review showed staff expected residents to be shaved as needed, with male residents usually shaved daily or first thing in the morning, and shaving was to be based on resident preference. The resident’s care plan identified an ADL self-care performance deficit related to shortness of breath and weakness, with personal hygiene/oral care requiring 1 staff to maximize independence. The MDS showed he was dependent for personal hygiene. His diagnoses included acute respiratory failure with hypoxia, congestive heart failure, COPD, macular degeneration, weakness, and acquired absence of the left upper limb below the elbow. The facility’s ADL policy stated residents unable to carry out ADLs would receive necessary services to maintain grooming and personal and oral hygiene.
Failure to Ensure Continuous Oxygen Availability
Penalty
Summary
The facility failed to ensure that R6 had oxygen available when needed. On 7/8/2026 at 11:20 AM, R6 was observed sitting in a wheelchair in her room with oxygen via nasal cannula, appearing short of breath with a respiratory rate of 30 breaths per minute. The nasal cannula was attached to a portable tank on the back of her wheelchair, but the tank meter showed it was empty. R6 also had an oxygen concentrator in her room and stated that staff tell her to breathe in through her nose and out through her mouth when she is short of breath, but she could not breathe through her nose if there was no oxygen. Staff were alerted that she needed help, and at 11:31 AM the RN confirmed the portable oxygen tank was empty. The RN then switched R6’s nasal cannula to the concentrator in her room and turned it on so she received oxygen at 2 liters per nasal cannula. The RN stated she did not realize R6 had returned from an appointment yet and that R6 should have been changed from the portable tank to the concentrator when she returned. The RN also stated it was important for R6 to have her oxygen because she becomes short of breath. R6’s physician orders for July 2026 showed oxygen at 2 liters per nasal cannula continuously every day and evening shift for oxygen levels regulated. R6’s care plan dated 6/8/26 identified risk for ineffective breathing pattern related to nodular density infiltrate of the right lung and glass opacity of the left lung.
Puree Diet Menu Not Followed
Penalty
Summary
The facility failed to follow the posted menu for residents on a puree diet for 3 of 3 residents reviewed for diets, including R46, R53, and R57. On 7/7/26, the cook stated the facility had 3 puree diets to prepare for the noon meal and that the kitchen pureed only 2 items for the meal, which were the Swiss steak and peas. The posted noon menu included creamy Swiss steak, garlic mashed potatoes, buttered peas, bread/margarine, and an iced oatmeal cookie bar, but the cook did not puree the dessert and instead replaced it with applesauce during lunch service for R57. The cook stated the kitchen does not puree desserts and substitutes applesauce, pudding, or ice cream, and said she had always been told there were only 2 items to puree. The Dietary Manager later stated that all items on the menu should be pureed, including desserts, and that there is a recipe in the binder for the puree dessert. R57 stated she was on a puree diet because she could not chew too well and said she always received applesauce, pudding, or ice cream for dessert, though she would try another dessert if it could be pureed so she could swallow it.
Puree Diets Not Prepared According to Recipe
Penalty
Summary
The facility failed to prepare puree diets according to the recipe for 3 residents on puree diets. During the noon meal preparation, the cook stated there were 3 puree diets to prepare and that the kitchen purees 2 items for the meal. The lunch menu included creamy Swiss steak, garlic mashed potatoes, buttered peas, bread and margarine, and an iced oatmeal cookie bar. The cook was observed placing the Swiss steak into the robot coupe and, after pureeing it, adding cold milk to the mixture before placing it back into the steamer. At 10:30 AM, the reheating temperature of the steak was 148 degrees, and the cook stated it should have been 165 degrees to be served. The puree recipe for creamy Swiss steak required beef broth prepared from soup base and boiling water, combined with thickener and gradually added to the meat. The cook reviewed the recipe and acknowledged she should have used broth instead of milk. The dietary manager stated she would expect the cook to follow the recipe for puree foods and noted that using milk in the steak would decrease the temperature because it is a cold liquid.
Missing EBP Signage for Residents Requiring Precautions
Penalty
Summary
The facility failed to have proper signage for residents on Enhanced Barrier Precautions (EBP). Three residents reviewed for EBP—one with a tracheostomy, one receiving dialysis, and one with bilateral lower-extremity wounds—did not have visible EBP signage on their doors during multiple observations. In each case, a yellow cubby rack containing PPE was on the door, and the EBP sign was either not visible or not posted where staff and visitors could readily see it. For the resident with a tracheostomy, the care plan and physician orders indicated EBP use, and the facility’s EBP policy stated residents with tracheostomies should be in EBP. The Assistant Director of Nursing/Infection Preventionist stated the resident should have EBP signage on the door so staff and visitors would know the precautions required, and then lifted the PPE bin to reveal a sign that had been hidden from view. For the resident on dialysis, the care plan and physician orders also indicated EBP use, the policy identified dialysis residents as requiring EBP, and the same staff member stated there was no visible EBP posting at the door. For the resident with wounds to both lower legs, no EBP sign was up when observed, and the wound care process included the wound physician debriding necrotic tissue while the ADON applied dressings afterward. During that dressing change, wound care supplies were placed on a soiled disposable pad, and the ADON later acknowledged this was a problem due to infection control. The resident’s care plan identified EBP related to wounds, and the facility’s policy stated residents with wounds such as chronic ulcers should have an order for EBP and that the facility would communicate which residents required EBP before high-contact care activities.
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 167 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 | ★★★★★ | 14 | 0 |
| Allure Of Stockton | 16.5 mi | ★★★★★ | 0 | 0 |
| Manor Court Of Freeport | 17.6 mi | ★★★★★ | 30 | 0 |
| Eagle Point Nursing And Rehabilitation | 19.2 mi | ★★★★★ | 7 | 0 |
| Serenity Estates Of Lena | 19.7 mi | ★★★★★ | 15 | 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 October 2026) and official state health department websites.