A list of the most recent deficiencies for Allure of Mendota. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-20 | 2023-11-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-20 | 2023-11-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-20 | 2023-11-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-10-20 | 2023-11-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-20 | 2023-11-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-20 | 2023-11-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-20 | 2023-11-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-20 | 2023-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-20 | 2023-11-10 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-10-20 | 2023-11-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-10-26 | 2023-11-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-26 | 2023-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-26 | 2023-11-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-26 | 2023-11-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-26 | 2023-11-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-12 | 2022-10-28 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-12 | 2022-10-28 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-21 | 2022-10-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-21 | 2022-10-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-22 | 2022-10-14 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-22 | 2022-10-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-09-22 | 2022-10-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-22 | 2022-10-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-21 | 2022-10-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-21 | 2022-10-07 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-08 | 2021-12-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-08 | 2021-10-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-09-08 | 2021-10-05 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-08 | 2021-10-04 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Establish methods for sharing information. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-08 | 2021-10-01 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-20 | 2021-09-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-09 | 2021-03-23 | Y |
