Health inspection·September 1, 2023

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. R16's face sheet showed a [AGE] year-old female with diagnosis of heart failure, cardiomyopathy, respiratory failure, pneumonia, multisystem inflammatory syndrome, intracranial hemorrhage, myoclonus, chronic pain syndrome, Raynaud's syndrome, and chronic kidney disease Stage 3. On 08/31/23 at 09:16 AM, V2 Director of Nursing (DON) said R16 had an order for daily weights and were not being done. V2 said it was her expectation daily weights were being done if they are ordered. It's important for R16 because of her cardiac issues and edema (fluid retention). If daily weights are not done, she could have cardiac issues, shortness of breath, and her medications may need to be adjusted. R16's POS showed a 3/22/23 order for daily weights, and an order for diuretic (medication to treat fluid retention). R16's 6/21/23 facility assessment showed she was cognitively intact, required extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. The facility's undated weight monitoring Policy showed weight can be a useful indicator of nutritional status. The physician should be informed of a significant change in weight and may order nutritional interventions. The Registered Dietician or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. The National Institutes of Health website showed diuretics are used in cardiomyopathy to remove extra sodium and fluid from the body. The American Heart Association website showed daily weights should be tracked. Many people are first alerted to worsening heart failure when they notice a weight gain of more than two to three pounds within a 24-hour period or more than five pounds in a week. R16's weights as documented showed: 8/28/2023 15:30 126.4 Lbs Chair, W/C Scale 8/25/2023 11:20 131.6 Lbs Chair, W/C Scale 8/19/2023 13:17 131.4 Lbs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 2 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Wheelchair Level of Harm - Minimal harm or potential for actual harm 8/18/2023 15:25 131.0 Lbs Residents Affected - Few Chair, W/C Scale 8/15/2023 12:55 126.8 Lbs Chair, W/C Scale 8/15/2023 10:21 126.8 Lbs Wheelchair 8/8/2023 17:59 127.5 Lbs Chair W/C Scale 8/1/2023 14:17 128.3 Lbs Chair, W/C Scale 7/28/2023 16:14 128.0 Lbs Chair, W/C Scale 7/25/2023 14:29 125.8 Lbs Chair, W/C Scale 7/23/2023 13:17 129.0 Lbs Wheelchair 7/21/2023 15:27 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 3 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 123.9 Lbs Level of Harm - Minimal harm or potential for actual harm Chair, W/C Scale 7/20/2023 13:39 Residents Affected - Few 123.5 Lbs Chair, W/C Scale 7/18/2023 13:34 123.0 Lbs Chair, W/C Scale 7/16/2023 13:21 119.6 Lbs Chair, W/C Scale 7/12/2023 10:51 121.8 Lbs Wheelchair 7/11/2023 11:37 121.4 Lbs Wheelchair 7/10/2023 13:12 120.4 Lbs Sitting 7/8/2023 10:01 119.4 Lbs Chair, W/C Scale 7/5/2023 17:31 123.4 Lbs Chair, W/C Scale (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 4 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 7/4/2023 13:24 Level of Harm - Minimal harm or potential for actual harm 121.6 Lbs Chair, W/C Scale Residents Affected - Few 7/3/2023 12:47 121.6 Lbs Chair, W/C Scale FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 5 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure physician prescribed treatments were in place for a resident with an unstageable wound (R62) and failed to ensure pressure ulcer interventions were in place for a resident at risk for wound development (R166) for 2 of 4 residents reviewed for pressure ulcers in the sample of 17. Residents Affected - Few The findings include: 1. R62's face sheet printed on 8/31/23 showed diagnoses including but not limited to fractured left femur, artificial left hip joint, protein-calorie malnutrition, and arthritis. R62's facility assessment date 7/29/23 showed no severe cognitive impairment and an unstageable pressure ulcer present on admission. The same assessment showed extensive staff assistance required for bed mobility, transfers, dressing, toilet use, and personal hygiene. The assessment showed R62 is incontinent of urine and bowel. R62's Wound Evaluation Summary dated 8/22/23 showed an unstageable pressure ulcer to sacrum (area at the base of the lower back) measuring 2.5 x 2.3 x 0.9 centimeters. R62's August 2023 physician order report showed an order dated 8/8/23 for: Cleanse the wound with normal saline, apply santyl ointment, cover with calcium alginate, apply bordered gauze daily in the evening. The report showed a second order to provide the same wound care as needed for soiling, saturation, and displacement. On 8/29/23 at 9:32 AM, R62 was lying on her side in bed. R62 said she had a sore on her back that has been there since she arrived. R62 said staff put cream and a bandage on it every few days. On 8/30/23 at 1:45 PM, V11 and V12 (CNAs-Certified Nurse Aides) rolled R62 to her left side and removed an incontinence brief. R62's sacrum had a golf ball size open wound with gray discharge oozing into the brief. The wound did not have any dressing and was completely open to the incontinence brief. V12 stated R62 should always have a dressing on the wound and was not sure why it was missing. V12 said the nurse should have been notified right away when the dressing comes off, is dirty, or loose. V12 stated the wound will not heal right if it is not covered. On 8/30/23 at 1:54 PM, V6 (Licensed Practical Nurse) said R62 has orders for wound care to be done on each night shift and as needed if the dressing comes off. V6 said the treatment and dressing are important to stop infection and keep incontinence out of the wound. Keeping it as clean as possible is important to promote healing. V6 said she had not received any report of a missing dressing to R62's sacrum. On 8/31/23 at 10:01 AM, V2 (Director of Nurses) stated wound treatments are important to stop the wound from getting worse and to get it to heal. Open wounds have the potential for infection and general health decline. V2 said all dressings that are missing, soiled, or loose should be replaced as soon as it is found. V2 said wound treatments are documented on the TAR (Treatment Administration Record). If the TAR is blank, that is an indication the treatment was not preformed. R62's August 2023 TAR was reviewed from 8/9 to 8/30 (22 days). The TAR showed 16 missing wound treatments not documented as having been done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 6 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm R62's care plan showed a focus area 7/22/23 related to the unstageable sacrum pressure ulcer. Interventions included: Provide skin care per facility guidelines and as needed. 2. R166's face sheet showed an [AGE] year-old female admitted to the facility 8/24/23 with diagnosis of dementia, history of falling, fracture of right femur, and presence of a right artificial hip joint. Residents Affected - Few On 08/30/23 at 07:43 AM, R166 was in bed on her back. There were socks on both feet and her heels were resting on the mattress. There was an air mattress on the bed, and it was in the off position. At 8:11 AM, during morning care, R166's coccyx was very reddened. Her right heel very reddened with a circular area of purple hue approximately 0.2 centimeters in circumference. R166's left heel was reddened. V10 Certified Nursing Assistant (CNA) and V14 CNA observed the skin concerns with this surveyor. R166's air mattress was off. On 08/31/23 at 09:23 AM, V2 Director of Nursing (DON) said there were no notes in R166's record about the skin concerns. V2 said she would have expected the CNAs to notify the nurse of any new skin concerns so the nurse could assess the area, add a treatment, see if nutritional interventions were needed, and to notify the family. There was no progress note the nurse was notified or any nursing skin assessment done. It's important that interventions are working and followed through to prevent wounds and pressure areas. She (R166) is not as mobile, is at risk for pressure due to the recent hip fracture and should have pressure care plan. R166's physician orders showed no offloading interventions for pressure injury prevention. R166's care plan had no focus area, goals or intervention identifying the potential risk for skin breakdown. There was no care plan regarding nutrition. R166's 8/24/23 facility assessment showed she was not cognitively intact. This assessment showed she required extensive assistance of two plus persons for bed mobility, transfer, dressing, toilet use, and personal hygiene. R166's 8/24/23 pressure risk assessment showed she was at a moderate risk for developing pressure. The facility's 4/2020 Prevention of Pressure Injuries Policy showed to establish and implement a nutrition care plan for any resident with or at risk of a pressure injury who is malnourished or at risk for malnutrition. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Select appropriate support surfaces based on the resident's risk factors in accordance with current clinical practice. Evaluate, report and document potential changes in the skin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 7 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement interventions to prevent a resident from falling for 1 of 7 residents (R59) reviewed for falls in the sample of 17. The findings include: R59's face sheet printed on 8/30/23 showed diagnoses including right sided hemiplegia (paralysis), expressive language disorder, metabolic encephalopathy, anxiety, dysphagia (difficulty swallowing), and unsteadiness on feet. R59's facility assessment dated [DATE] showed severe cognitive impairment and extensive to total staff assistance needed for bed mobility, transfers, locomotion, dressing, eating, toilet use, and hygiene. On 8/29/23 at 12:47 PM, R59 was lying asleep in a low bed and two fall mats were next to the bed. The call light was out of reach. There was not any type of bed alarm on the bed. R59's room was at the far end of the hall, one room away from the emergency exit door. There were not staff present in the hallway. On 8/30/23 at 9:57 AM, V9 and V10 (CNAs-Certified Nurse Aides) transferred R59 from a high back wheelchair to the bed using a mechanical lift. V9 and V10 checked R59 for incontinence and lowered the bed. R59 was confused and slightly resistive during the care. A pillow was placed behind R59's back and the fall mats were placed on the floor. V10 said R59 has rolled out of bed several times in the past, but she did not think there had been recent falls. At 1:21 PM, V9 (CNA) and V1 (Administrator/CNA) were providing incontinence care to R59. R59 was rolling side to side in bed and very resistive to care. R59 was confused and yelling out in nonsense words. At 2:06 PM, R59 was lying in a low bed, fully naked with the room door closed. V14 (CNA) entered and said R59 refused to be dressed right now. V14 began to change R59's bed linens. R59 was able to roll side to side independently after cueing from V14. R59's care plan showed a focus area start dated 4/7/23 (3 days after admission) related to falls as evidenced by actual falls. The care plan listed 12 falls since admission and the most recent fall on 8/27/23. Interventions included frequent visual checks (R59 resides at the end of the 200 hall) and utilize devices as appropriate to ensure safety (i.e., bed mats, sensor alarms, etc.). R59's progress notes were reviewed and showed the falls were caused by R59 rolling out of bed. On 8/31/23 at 10:05 AM, V2 (Director of Nurses) stated there have been several fall interventions attempted to stop R59 from falling out of bed, but none have worked. R59 has behaviors and can turn or roll 360 degrees in bed. Medication has not been helpful because she spits pills out many times. R59's family has refused topical type medications. All we can do is educate staff to check on her frequently. V2 said R59 would benefit being placed in a room closer to the nurse station but her yelling out upsets the other residents. R59 needs to be in a room by herself and the one she is currently in is the only one available. V2 said they have not attempted placing the mattress directly on the floor. V2 said she did not know why, they just haven't yet. V2 said the plan going forward to prevent R59 from falling is to continue the frequent checks, find alternative placement for her, and educate the family on the need for medication. V2 said she was not sure any of that would work to stop R59's falls. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 8 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm The facility Fall Reduction Program policy dated 12/2021 states: It is the policy of this facility to have a Fall Reduction Program to assure the safety (of) all residents in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Program will monitor the program to assure ongoing effectiveness. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 9 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to prevent severe, unplanned weight loss (R59) and failed to implement a nutritional supplement (R1) for 2 of 2 residents reviewed for nutrition in the sample of 17. Residents Affected - Few These failures resulted in R59 sustaining a 21.36 % weight loss over 5 months. The findings include: 1. R59's face sheet printed on 8/30/23 showed diagnoses including right sided hemiplegia (paralysis), expressive language disorder, metabolic encephalopathy, anxiety, dysphagia (difficulty swallowing), and unsteadiness on feet. R59's facility assessment dated [DATE] showed severe cognitive impairment and extensive to total staff assistance needed for bed mobility, transfers, locomotion, dressing, eating, toilet use, and hygiene. The same assessment showed no or unknown regarding any loss of weight over 5% or more the last month or loss of 10% or more in the last 6 months. R59's August 2023 physician order report showed an order dated 6/22/23 for a low concentrated sweets diet, pureed texture, thin consistency. The report did not have any orders for any weight supplement or how often weights should be done. On 8/29/23 at 11:35 AM, R59 was seated in a high back wheelchair in the main dining room. R59's eyes were closed, and her mouth was a gap while V13 (Certified Nurse Aide) fed her a pureed textured meal. V13 was able to drink and swallow after cueing from V13. On 8/30/23 this surveyor reviewed R59's weights from 4/3/23 (date of admission) to 8/24/23 (last recorded weight). Results indicated at 21.36% weight loss in five months, a 9.16% weight loss in three months, and a 6.3% weight loss over the last one month. R59's progress notes were also reviewed. There were only two nutrition progress notes which were dated 4/29 and 6/25. Neither note had any indication of significant weight loss concerns. Both notes showed a plan to continue monitoring, follow with registered dietician for consult as needed, and continue to monitor weights as needed. On 8/31/23 at 12:06 PM, V1 (Administrator) stated she is the current acting dietary manager. V1 said resident weights are reviewed by V4 (Registered Dietician) and V2 (Director of Nurses). V1 said all residents are weighed on their once or twice a week shower day. V2 reviews the weights weekly and V4 reviews them monthly. Weights are reviewed and discussed weekly on Thursdays at the risk management meeting. Any resident with a big weight gain or decrease is discussed. V4 does the nutritional recommendation for residents with big weight decreases. The recommendation is approved by the physician and put on the order report. V1 said it is important for the recommendations to be on order as soon as possible to stop the weight loss. V1 said large weight losses can lead into other medical issues. V1 stated residents on a puree diet have an even greater risk of weight loss. V1 reviewed R59's weights in the electronic medical record and said there has been a gradual significant weight loss during R59's time here. V1 said she had no idea why it had not been noted earlier or why interventions had not been put in place sooner. On 8/31/23 at 12:50 PM, V4 (Registered Dietician) stated she reviews residents' weights monthly. V4 said the dietary manager left the facility around July 7 and she has been the one watching weights on a weekly basis since then. V4 said she charts weight changes if there is any change of 5 pounds (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 10 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Level of Harm - Actual harm Residents Affected - Few or more. V4 said if there is nothing charted, then she did not have any problem with a resident's weight. V4 said she documents in the resident's nutritional notes any concerns and recommendations she has. The note is sent to the director of nurses to be approved by the physician or nurse practitioner. V4 said it is important to identify weight loss soon to avoid the potential for weakness, reduction in normal activities of daily living, or overall health. V4 said unchecked weight loss could exacerbate current medical conditions. V4 said nutritional recommendations need to be implemented sooner versus later to see if they are working or not. V4 defined a significant weight loss of 5% in one month, 7.5% in three months, and 10% in 6 months. V4 said yesterday (8/30) was the first time she had time to document R59's nutritional notes and did not have any dietary recommendations before then. V4 said yesterday was the first time she had recommended any dietary interventions in regard to R59's significant weight loss. R59's progress notes showed a nutritional note dated 8/30/23 at 3:11 PM (during the survey) for a recommendation to notify MD of 10.1-pound weight decrease in the last month, which indicates a significant weight loss. Add a health shake daily to aid in weight stability. R59's care plan also showed a newly added focus for an unplanned/unexpected weight loss start dated 8/31/23. All interventions were also start dated 8/31/23. The facility's undated Weight Monitoring policy states under the policy section: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. The policy further states: 4. Interventions will be identified, implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status. 2. R1's face sheet showed an [AGE] year-old female with diagnosis of mild protein calorie malnutrition. asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, dyspnea, dementia, kidney failure, type 2 diabetes, heart failure, and rheumatoid arthritis. R1's physician order sheet showed a 6/23/23 order for a health shake three times daily. On 08/29/23 at 12:05 PM, R1 was in the dining room in a wheelchair. R1 was feeding herself a grilled cheese sandwich and complained it was salty. On 08/30/23 at 07:42 AM, R1 was in the dining room feeding herself a toast and egg sandwich. On 08/31/23 at 09:13 AM, V2 Director of Nursing said (while reviewing R1's medical record) she doesn't find any evidence that a health shake was given as ordered until the end of June. V2 confirms R1's 5/14/23 physician order for a health shake to be given daily. V2 also confirmed a significant weight loss noted from May to June 2023. V2 said a health shake three times a day was ordered on 6/23/23. V2 said it is her expectation that residents receive dietary supplements as ordered. V2 said the May health shake order did not show up on her medication administration record (MAR). If they don't receive the supplements they may experience continued weight loss, wounds, an overall decline, and weakness. R1's weight record showed the following: 5/3/23 weight-192 pounds, 6/3/23 weight-174.4 pounds. A 9.17 % weight loss in one month. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 11 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 R1's 5/14/23 dietary note authored by V4 Dietician showed a significant weight loss of 6.1% in the last month. V4 recommended to add a health shake daily to aid in weight stability. Level of Harm - Actual harm Residents Affected - Few R1's 6/17/23 dietary note authored by V4 showed another significant weight loss of 8.3% in the last month. V4 recommended to increase health shakes to three times daily. R1's May 2023 medication administration record (MAR) did not show the health shake order. R1's June 2023 MAR showed a health shake was given once a day on 6/21 and 6/22/23. R1's nutrition care plan has no intervention for a dietary supplement or mention of her significant weight loss. R1's 7/25/23 facility assessment showed moderate cognitive impairment and requiring extensive assistance for bed mobility, transfer, dressing, personal hygiene and bathing. This assessment showed weight loss while not on a physician prescribed weight-loss program. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 12 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's oxygen tubing was changed weekly and failed to ensure a resident's oxygen was on during administration for 3 of 4 resident's reviewed for oxygen in the sample of 17. Residents Affected - Few The findings include: 1. R34's face sheet showed a [AGE] year-old male with diagnosis of dementia, chronic obstructive pulmonary disease, pneumonia, respiratory failure, hypertension, heart failure, chronic kidney disease Stage 3, and cognitive communication deficit. On 08/29/23 at 12:36 PM, R34 was in the dining room seated at a table with two other male residents in the facility's locked dementia unit. R34 had oxygen tubing in his nose but the flowmeter on the portable concentrator was set at zero (no oxygen being administered). The oxygen tubing was dated 8/21/23. R34 ambulated with the assistance of V15 Certified Nursing Assistant (CNA) to his room. When this surveyor entered the room, R34 was on the toilet without oxygen on. The portable concentrator was on a dresser. V15 was asked what it meant if the red flowmeter showed a zero and she referred the question to the nurse. There was a continuous positive airway pressure (CPAP) machine and tubing at R34's bedside dated 8/21/23. At 12:50 PM, R34's portable tank was shown to V6 Licensed Practical Nurse (LPN) who verified if the tank flowmeter was set at zero, no oxygen was being administered. On 08/30/23 at 11:34 AM, R3's oxygen, nebulizer, CPAP tubing and humidifier were all dated 8/21/23. On 08/31/23 at 09:04 AM, V2 Director of Nursing (DON) said if a resident's sats (oxygen saturations) are 90 or below, we put them on oxygen. It's important for oxygen administration for the oxygen flowmeter to be turned on so they're getting the oxygen. If they're not receiving the oxygen, they could become hypoxic (low oxygen level). Oxygen, nebulizer and cpap (continuous positive airway pressure) tubing should be changed weekly to prevent bacteria and to keep it clean. If this isn't done, it could lead to having respiratory issues. Oxygen, nebulizer and CPAP tubing should be in a zip lock bag for storage to keep it from falling on the floor, and to prevent contamination. The nurses date a piece a tape and attach to the tubing to keep track of when it needs to be changed. R34's physician order sheet (POS) showed oxygen (O2) per nasal cannula. Titrate O2 to keep saturation above 90 %. Change oxygen and nebulizer tubing every Sunday night on night shift. Continuous positive airway pressure (CPAP) at bedtime for sleep apnea. R34's care plan showed to evaluate pulse oximetry and provide oxygen as indicated by resident condition and/ or provider order. R34's CPAP care plan showed to provide CPAP and care as ordered. R34's 7/8/23 facility assessment showed he was not cognitively intact. This assessment showed R34 required extensive assistance of one person to physically assist for dressing, toilet use, and dressing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 13 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility's undated Oxygen Administration Policy showed oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia. Oxygen is administered under orders of a physician, except in the case of emergency. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. If applicable, change nebulizer tubing and delivery devices every 72 hours or per facility policy and as needed if they become soiled or contaminated. Keep delivery devices covered in plastic bag when not in use. 2. R1's face sheet showed a [AGE] year-old female with diagnosis of asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, dyspnea, dementia, kidney failure, type 2 diabetes, heart failure, rheumatoid arthritis, and mild protein calorie malnutrition. On 08/29/23 at 09:41 AM, R1was seated on a recliner in her room. She had oxygen on via a humidified concentrator set at 2 liters per minute. R1's oxygen humidifier container was dated 8/21/23. There was an open gallon jug of distilled water on the floor between the recliner and a bedside table. The water gallon was dated 6/22. R1 was sniffling and picking her nose. There was no date on the oxygen tubing. At 12:05 PM, R1 was in the dining room. She had her oxygen on and there was no date on the tubing. R1 asked a staff member to wipe her nose as she is eating her grilled cheese sandwich. On 08/30/23 at 07:42 AM, R1 was in the dining room. There was no date on her oxygen tubing. On 8/31/23 at 7:55 AM, R1 was in her room. Her nebulizer mask was on top of (not inside of) a plastic baggie on the bedside table. The nebulizer mask was dated 8/21/23. R1 had oxygen at 2 liters per nasal cannula and the tubing remained undated. R1's POS showed to administer oxygen at 2-4 liters per nasal cannula continuous to keep saturation greater than 90%. Change oxygen and nebulizer every Sunday night and change oxygen water bottle monthly. R1's care plan showed she had a history of chronic obstructive pulmonary disease (COPD) and scheduled nebulizer treatments. R1's care plan showed to administer oxygen as prescribed or per standing order, evaluate pulse oximetry, and notes a resident history dated 8/30/23 of a respiratory infection. R1's 7/25/23 facility assessment showed moderate cognitive impairment and requiring extensive assistance for bed mobility, transfer, dressing, personal hygiene and bathing. 3. R3's face sheet showed a [AGE] year-old male with diagnosis of dementia, hypertension, and polyosteoarthritis. On 08/30/23 at 11:39 AM, R3's oxygen concentrator was in his room. R3 was not in his room. R3's oxygen humidifier was dated 7/7/23. R3 is in a private room in the locked dementia unit. On 08/30/23 at 07:59 AM, R3 was in the dining room for breakfast. R3 had oxygen per nasal cannula (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 14 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 being administered at 2 liters. Level of Harm - Minimal harm or potential for actual harm On 08/31/23 at 08:02 AM, R3 was in the dining room without oxygen on. There was an oxygen concentrator in his room running at 2 liters and a nasal cannula was connected and the tubing was draped over a bedside table. Residents Affected - Few On 8/31/23 at 9:04 AM, V2 DON said (while reviewing R3's medical record) his oxygen saturation had not been checked since 8/30/23. V2 said she would expect it to be checked if he was on oxygen during the night and was not on oxygen in the dining room at breakfast. R3's POS showed to administer oxygen at 1-4 liters per nasal cannula as needed to keep sats above 90%. Pulse oximetry two times a day (bid) and as needed (PRN) for shortness of breath (SOB). Change oxygen tubing/cannula/ mask every week at bedtime on Sunday. R3's care plan showed no focus areas, goals or interventions for oxygen use. R3's 8/30/23 facility assessment showed severely impaired cognitive status, FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 15 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0801 Level of Harm - Minimal harm or potential for actual harm Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review, the facility failed to provide the services of a dietary manager. This has the potential to affect all residents in the building. Residents Affected - Many The findings include: The facility's Resident Census and Condition Report dated 8/29/23 showed 61 residents residing in the building. On 8/29/23 at 9:03AM, V1 (Administrator) stated, We don't have a Dietary Manager right now. Our previous manager left on July 7, 2023. I have been filling the role the best that I can and our dietician is here once a month to help with ordering and monitoring weights. I don't have any type of certification, I'm just trying to help where I can. On 8/29/23 at 9:45AM, V5 (Cook) stated, The Dietary Manager left on July 7th. We don't really have anyone managing us so I have been doing a lot of the tasks that the manager would normally do. I created a new cleaning schedule because we didn't have one and I do the ordering sometimes. We run out of food so I have to substitute often. I can't keep track of the food supply and do my job with the hours that I work here. The dietician does come in once a month but I don't see her any more than that. She's been trying to help out with management type stuff I guess. On 8/30/23 during the resident council meeting, R9,R12,R19, and R53 all stated they have seen a decline in the dietary department since the dietary manager left. R53 stated the dietary manager used to come around during meals to ensure residents had everything they needed and got their feedback on the meals so she could make adjustments if needed. R12 stated the residents used to have a salad bar every day at lunch but that has stopped since the dietary manager left. R12 stated this affects a lot of the residents as some of them just wanted a small amount of food from the salad bar for lunch but now they only get to have a bowl of tomato soup. All residents agreed there are a lack of choices now that the dietary manager is gone and there is not a consistent person ordering food. On 8/31/23 at 12:50PM, V4 (Dietician) stated, I have been monitoring the weekly weights since the Dietary Manager left on July 7th. Typically, that's not a task of mine but I took it over when she left. I try to help the staff as much as I can but I haven't really been doing anything more than I normally do. (V1 and V5) have been picking up all the work of the dietary manager. (The survey team identified a resident (R59) with significant weight loss that had not been identified nor had nutrition recommendations been put into place). The facility was unable to provide a policy related to the role of the Dietary Manager. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 16 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to prepare and serve pureed foods per the recipe guidelines for 5 of 5 residents reviewed for pureed foods. This applies to 2 residents (R3,R59) in the sample of 17 and 3 residents (R14,R25,R26) outside of the sample. Residents Affected - Some The findings include: The facility's list of residents receiving a pureed diet included R3,R14,R25,R26, and R59. The facility's menu for 8/29/23 showed, Pork and mushroom stir fry (6oz) and saffron rice (4oz). On 8/29/23 at 10:32AM, V5 (Cook) prepared the pureed meat and rice for the lunch meal. V5 stated, For residents receiving the pureed meal today I am combining the rice and the meat together so it's more like a stir fry for them. V5 scooped five 4oz scoops of rice and five 6oz scoops of pork and mushrooms and placed them altogether in the blender. V5 stated, I will give them each a 6oz serving of the rice and meat because I figure I would do the larger portion due to the meat size being that amount for the recipe. During meal service, V5 gave each of the 5 residents receiving pureed food a 6oz scoop of the rice and meat mixture. On 8/31/23 at 12:52PM, V4 (Dietician) stated, (V5) should have followed the portion size on the extension sheet to ensure that residents are getting the proper nutrition. If she continues to give the amount she thinks is correct we could start seeing weight loss in these residents. The recipes are very specific to each diet type for this reason. The facility was unable to provide a policy regarding food preparation in relation to altered diets. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 17 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food storage and preparation areas were clean and free of insects. This applies to all residents in the facility. Residents Affected - Many The findings include: The facility's Resident Census and Condition Report dated 8/29/23 showed 61 residents residing in the building. On 8/29/23 at 9:52AM, the dry food storage had dead flies in all corners of the room and several dead wasps in the center of the room. V5 (Cook) stated there are a lot of insects that get into the dry storage room because it is right by the back door where the staff go in and out to take the trash out. V5 stated that staff are to sweep the storage room every Wednesday after the food shipment gets put away and as needed if they see it needs done. On 8/29/23 at 10:00AM, a tour of the kitchen revealed several bins with scoops and utensils in them with crumbs and debris sitting in the bottom of the containers. All of the containers were open and had no lids on them to prevent debris from falling into them. The containers for bulk rice, flour, and sugar were sticky and greasy to the touch. The top of the oven had a layer of a sticky, grease-like substance on it with clean pans placed upside down on top of it. The cupboard with the bread stored in it had large amounts of crumbs and various debris inside of it. V5 stated the staff used to have a cleaning scheduled but it didn't all apply to them so she created a new one to be implemented 9/1/23. On 8/29/23 at 3:05PM, V1 (Administrator) stated, We just deep cleaned the kitchen not long ago. I can't believe that it's already that dirty again. The staff should be cleaning when they see it needs to be done. I know we've had a cleaning schedule but I'm not sure who all of the responsibilities go to as far as each task. On 8/31/23 at 12:52PM, V4 (Dietician) stated, (V1-Administrator) has been taking care of making sure cleaning schedules are being followed. I don't do anything with that when I am at the facility. The facility's policy titled, Food Receiving and Storage dated 2001 showed, Foods shall be received and stored in a manner that complies with safe food handling practices .1. Food Services, or other designated staff, will maintain clean food storage areas at all times. The facility's cleaning logs for the past month were requested and not received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 18 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety Based on observation, interview, and record review, the facility failed to have a system in place to track or trend illnesses, failed to have a process in place to identify contagious residents, and failed to implement transmission-based precautions for resident exhibiting infectious illness. These failures resulted in 9 residents (R1,R8,R16,R22,R35,R45,R47,R54,R61) experiencing respiratory illness, 17 residents (R4,R10,R11,R13,R17,R18,R19,R21,R29,R33,R46,R50,R51,R53,R58,R59,R62) testing positive for COVID-19, and 3 residents (R4,R50,R58) being hospitalized for COVID-19. Residents Affected - Some The Immediate Jeopardy began on 8/26/23 when R22 and R45 began having symptoms of body pains, increased cough, and elevated temperatures. V1 (Administrator) and V3 (Regional Nurse) were notified of the Immediate Jeopardy on 8/31/23 at 1:47PM. The surveyor confirmed through observation, interview, and record review that the Immediate Jeopardy was removed on 9/1/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: Upon entrance to the facility on 8/29/23, no signage was posted indicating a respiratory outbreak in the facility. Staff and residents were not wearing masks. V1 (Administrator) stated no residents in the facility were currently on isolation. Residents were observed congregating in activity areas as well as participating in communal dining without face coverings. No personal protective equipment or isolation signs were observed at any resident rooms or doorways. A review of electronic medical records showed: On 8/26/23, R22 and R45 reported body pains and increased cough. R22 had a temperature of 99.7 degrees and R45's temperature was 102.3 degrees. On 8/27/23, R16 and R61 experienced body aches, malaise, and congestion. R47 experienced chest congestion and cough. R13 experienced body aches, malaise, and throat discomfort. R58 experienced a sore throat and cough. On 8/29/23, R35 experienced watery eyes and congestion. R1 experienced increased temperature and cough. R46 experienced a non-productive cough, increased drowsiness, congestion, and shortness of breath with exertion. R54 experienced a sore throat, productive cough with green phlegm, watery eyes, and a headache. R58 was sent to the local emergency room due to difficulty breathing and low oxygen saturations. R58 was diagnosed with COVID-19 in the emergency room. On 8/30/23, R62 experienced a cough with a sore throat. R50 experienced a loose, productive cough, increased shortness of breath, temperature 99.2 degrees, oxygen saturations 91% on 4 liters of oxygen, shaking, flush, and complaints of not feeling well. R50 was sent to the local emergency room and hospitalized with a diagnosis of COVID-19. On 8/31/23, R4 experienced increased lethargy, expiratory wheezing and crackles to all lung fields. R4 tested positive for COVID-19 and had a decline in respiratory status and was sent to the local emergency room and hospitalized . On 8/29/23 at 9:21AM, R61 stated she has had watery eyes, sore throat, plugged ears, chills, and a headache since 8/25/23. No isolation signs or personal protective equipment (PPE) was located outside of R61's door. Staff are observed not wearing face masks throughout the facility. On 8/29/23 at 11:23AM, R51 was in the dining room waiting for her meal to be served. R51 had a congested cough. R51 coughed up a moderate amount of phlegm in her hand and wiped it on her sweater. R51 was not wearing a mask and was participating in communal dining. (R51 tested positive for COVID-19 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 19 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 on 8/31/23) Level of Harm - Immediate jeopardy to resident health or safety On 8/30/23 at 8:33AM, V6 (Licensed Practical Nurse) was administering medications to R54. V6 stated, Today is her first day of her antibiotic for her upper respiratory infection. We have not been COVID testing any residents with respiratory symptoms since I started working here in March. (V6 then entered R54's room with no mask on. R54 was not on any type of isolation and no PPE was located outside of her room). Residents Affected - Some On 8/30/23, a list of all residents with current respiratory infections was provided to the survey team and showed 13 residents (R1,R8,R13,R16,R22,R35,R45,R46,R47,R50,R54,R61,R62) with current infections. The facility had not identified they were in outbreak status until the survey team requested this list. On 8/30/23 at 11:02AM, V3 (Regional Director of Operations) stated, I just called the local health department to report the outbreak. We put isolation bins outside all of the infected resident's rooms, and have started COVID testing all of the infected residents and so far they are negative. On 8/30/23 at 1:11PM, V2 (Director of Nursing/Infection Preventionist) stated, We just tested all of the residents who have respiratory symptoms for COVID-19 and they are all negative. The first resident who was sick was R45 I think and we COVID tested him right away because the doctor told us to. He was negative. We noticed different people (residents) coming up with respiratory symptoms and (V8-Nurse Practitioner) gave us standing orders for Robitussin, Azithromycin (antibiotic), and albuterol nebulizer treatments. Today is when I would have identified an outbreak, not before. (V1-Administrator) is the one who reports outbreaks to the health department when we have them. I would not have considered us to be in an outbreak until you pointed it out today. I didn't realize how many residents were ill. I have been keeping track of the illnesses but only jotting down notes. I don't have any official tracking form that I use. I can't use the facility floor plan either to identify trends because I can't read it. Up until today we were just encouraging any resident with respiratory symptoms to stay in their room and keep drinking fluids. If residents do come out of their room, they should be encouraged to wear a mask. If we have a resident test positive for COVID then they need isolate immediately and if they had a roommate that roommate should be tested on days 1, 3, and 5 and isolate until all tests come back negative. We definitely encourage good hand hygiene for residents and staff. Prior to today, nobody except (R45) had been tested. I should have started testing when residents were showing symptoms. I know that now and our corporate office informed me that I did not take the correct action nor did I track the illnesses in order to identify any trends in certain areas of the building. As soon as we had residents coming up with respiratory symptoms, I should have had the residents isolate to prevent the spread of the illnesses. On 8/30/23 at 2:45PM, R8,R13,R16,R19,R35,R45,R46,R47,R50,R54, and R61 had a sign posted on their door showing, Droplet Precautions: Everyone must clean their hands before entering and when leaving the room. No personal protective equipment was located outside any of the above resident's doors and staff were not wearing masks in the facility. Staff observed entering rooms showing Droplet Precautions were wearing surgical masks only. (Isolation was initiated 4 days after the first case of respiratory illness). On 8/30/23 at 3:30PM, a sign was posted on the entrance to the facility showing a respiratory outbreak within the facility. (4 days after the first resident experienced respiratory illness) On 8/30/23 at 3:09PM, V7 (Public Health Nurse) stated, I got an e-mail from (V1-Administrator) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 20 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some about 2 hours ago regarding the respiratory outbreak. In the past when we have had different respiratory outbreaks we have considered 2 or more an outbreak. The last time the facility reported any type of illness was in December 2022. What they are supposed to do is e-mail the infectious disease e-mail so that anyone in our department can respond to them. They should have COVID tested immediately and isolated residents. They should definitely be masking for everyone. This is very basic at this point and all facilities should know this. COVID-19 is making a comeback and is very much still prevalent and should have been on their radar. On 8/31/23 at 8:10AM, R50's door was closed and staff stated resident was sent to the hospital on 8/30 due to COVID+ status. Staff not wearing masks throughout facility, no PPE located outside infected resident rooms. On 8/31/23 at 8:16AM, V1 stated, (R50) was sent to the hospital last night and is now our second COVID positive case. (R58) was our first one on 8/29. We did not test anyone after the first positive and we didn't isolate or test (R58's) roommate. I guess I just didn't think about it because we haven't had to do this for so long. We haven't had a COVID positive in months. The health department did e-mail me back last night and told me to just keep doing what we are doing because they had already talked to (V3). We are going to test every resident on (R50's) hall this morning. On 8/31/23 at 9:04AM, V7 (Public Health Nurse) stated, I spoke with (V3) yesterday and the facility informed me they were doing increased monitoring for respiratory signs/symptoms, placed isolation buckets outside of the infected resident's rooms, and that staff were wearing gowns, masks, gloves in the isolation rooms. I recommended they keep doing that and I also spoke to her about RSV (Respiratory Syncytial Virus) and Influenza and she said that wouldn't really matter because they already started antibiotics. I informed her that these are viral so it would be beneficial to test. I recommended they do respiratory panels on all residents. They said they can't do that without a physician's order and I said okay. I did not tell them if they wanted to do it they could. It is highly recommended to do further testing if the COVID tests come back negative so we can identify exactly what illness we are dealing with. I would have expected to have been notified of their first positive COVID case so I could track it and keep in contact with the facility and help identify and trends or give recommendations to help slow the spread. I highly doubt the first COVID+ resident's symptoms started on 8/29/23 so the roommate should've been tested earlier than 8/30/23. (V3) reported to me that no residents have experienced a fever thus far. (At this time, 3 residents had reported increased temperature) On 8/31/23 at 12:05PM, V8 (Nurse Practitioner) stated, If residents are displaying respiratory symptoms, you definitely should isolate them until you know that symptoms are resolving to prevent spreading the illness. I would have thought with their nursing judgement that they would have done the antigen testing in house. As a matter of fact, when I was notified of the first COVID positive case I told the staff, I sure hope you're going to be testing the rest of the residents. I assumed they would have done that per their policy but apparently not. This definitely could have been less severe of an outbreak if they had isolated the residents and used personal protective equipment like they were supposed to. If you have a sign on the door that says droplet precautions then you have to have gowns, masks, and gloves outside the door, available for staff to put on PRIOR to entering the room or they are not protected against any illness that resident has. On 8/31/23 at 12:42PM, The facility completed their outbreak testing for COVID-19 on the entire facility and provided a list of 17 total residents (R4,R10,R11,R13,R17,R18,R19,R21,R29,R33,R46,R50,R51,R53, R58,R59,R62) who tested positive for COVID-19 in the facility. Two resident's (R50,R58) are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 21 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 currently hospitalized with COVID-19. Level of Harm - Immediate jeopardy to resident health or safety On 9/1/23 at 9:42AM, V3 (Regional Director of Operations) stated, (R4) was sent to the hospital last night due to declining condition and was one of our COVID positive residents. Residents Affected - Some The facility's policy titled, Infection Control Policy and Procedure for COVID-19 Facility Response Strategy dated 5/25/23 showed, COVID-19 testing is required for any of the following: Symptomatic residents or healthcare providers (HCP), even those with mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for COVID-19 as soon as possible. Implement recommended infection prevention and control practices when caring for a resident with suspected or confirmed COVID-19 infection. Asymptomatic residents and HCP with a close contact or higher-risk exposure are recommended to have a series of three viral tests for COVID-19 infection .Outbreak testing: A broad-based approach includes the unit, floor, or other specific area of the facility where the positive COVID-19 case was identified. The facility's policy titled, Infection Prevention and Control Program dated 5/1/23 showed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection as per accepted national standards and guidelines .1. The designated infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases .9. COVID-19 testing: a. anyone with symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. The facility's policy titled, Transmission-Based (Isolation) precautions dated 2023 showed, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission .10. Droplet Precautions- e. healthcare personnel will wear a facemask for close contact with an infectious resident. F. based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. The Immediate Jeopardy that began on 8/26/23 was removed on 9/1/23 when the facility took the following actions to remove the Immediacy and correct the noncompliance. The facility implemented the following abatement plan after a meeting was conducted by the appropriate members of the Quality Assurance Performance Improvement (QAPI) Committee held on 8/31/23 at 3:30PM. 1) Corrective actions which will be accomplished for those residents found to be affected by the deficient practice. a. All residents has been tested for COVID. All residents who are listed as positive for covid are either in the hospital or have been placed on droplet isolation. The isolation rooms have the appropriate signs and PPE. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 22 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 b. Level of Harm - Immediate jeopardy to resident health or safety All residents who have respiratory signs and symptoms have been placed on droplet precautions. The resident rooms have the appropriate signs and PPE. c. Residents Affected - Some Health department notified of respiratory illness on 8/30/23 @ 3:38PM by (V3-Regional Director of Operations) d. Health department notified of COVID outbreak on 8/31/23 @ 9:48AM by (V1-Administrator). Ongoing communication has been conducted with the health department by (V1). e. All staff and residents will wear proper PPE and source control f. All current staff in the facility have been tested for covid. All staff that have not been tested for covid will be tested prior to their next shift. g. All communal dining and activities have been put on hold to prevent the spread of covid. h. All staff including agency staff will be in-serviced by (V3), (V1), (V2) on: covid policy, hand washing, PPE, testing residents for covid that have respiratory signs and symptoms, implementing transmission-based precautions. In-servicing will be conducted either via phone or in person prior to their shift. 2) How the facility will identify other residents having the potential to be affected by the safe deficient practice. a. All residents have the potential to be affected. All residents in the facility have been tested for covid. This was completed on 8/31/23. The QAPI meeting was conducted on 8/31/23 and reviewed: 1) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 23 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Notifying the local health department to obtain guidance on illness outbreak Level of Harm - Immediate jeopardy to resident health or safety 2) Residents Affected - Some 3) The facility discussed the local health department guidance on the illness outbreak The facility discussed the plan for training all staff, including administration regarding response to illness outbreak 4) Review of IJ for F880 5) Review of facility abatement plan 6) Review of infection prevention control program policies 7) Review of covid policies 8) Review or PPE policies 9) Review of handwashing policies 10) All residents with respiratory signs and symptoms need to be tested for covid 11) The facility's policies on infection control 12) Transmission based precautions policy 13) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 24 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 When to implement isolation and transmission-based precautions. Level of Harm - Immediate jeopardy to resident health or safety 3) The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. Residents Affected - Some a. In-service training done by (V21-Chief Nursing Officer) with (V3) on 8/31/23 on covid policy, handwashing, ppe, testing residents for covid that have respiratory signs and symptoms, response to illness outbreak, policies and procedures regarding implementing transmission based precautions for residents actively displaying symptoms of respiratory illness, and the procedure on when to notify the local health department to obtain guidance on illness outbreak. b. In-service training done by (V3) with (V1) and (V2) on 8/31/23 on covid policy, handwashing, ppe, testing residents for covid that have respiratory signs and symptoms, response to illness outbreak, policies and procedures regarding implementing transmission based precautions for residents actively displaying symptoms of respiratory illness, and the procedure on when to notify the local health department to obtain guidance on illness outbreak. c. The facility completed in-service training for all staff by (V3), (V1), and (V2) on covid policy, handwashing, ppe, testing residents for covid that have respiratory signs and symptoms, response to illness outbreak, policies and procedures regarding implementing transmission based precautions for residents actively displaying symptoms of respiratory illness, and the procedure on when to notify the local health department to obtain guidance on illness outbreak. All staff will be educated in person or via telephone on 8/31/23 or prior to their next scheduled shift. All staff are expected to be in-service by 9/8/23. 4) Quality Assurance plans to monitor facility performance to make sure that corrective actions are achieved and are permanent DON/ADON or designee will continue to conduct a QA study to determine: a) Does the resident exhibit respiratory symptoms, were they tested for COVID-19? b) Were proper precautions implemented for COVID positive residents and for residents actively displaying symptoms of respiratory illness? (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 25 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 c) Level of Harm - Immediate jeopardy to resident health or safety Was resident isolated per facility policies and procedures? Residents Affected - Some Was local health department notified of covid positive residents and for residents actively displaying symptoms of respiratory illness for guidance, per facility policy? d) e) Was proper signage and equipment in isolation rooms? f) Did staff use proper PPE and hand hygiene? g) Did staff follow facility's policies pertaining to infection control and response to illness outbreak? The DON/ADON or designee will conduct the QA study at least 3 times per week for a period of 3 months with the facility created QA tool to maintain compliance with this regulation. The results of this tool will be reviewed during the facility's quarterly QA meetings. Any issues identified will be immediately corrected. Administrator or designee will monitor for overall compliance. On 9/1/23 at 11:00AM, a review of the facility's in-service record showed all staff working the remainder of the day on 8/31/23 and staff working on 9/1/23 were in-serviced on infection control procedures consisting of identifying and monitoring residents for symptoms, notification to the nurse for residents identified as having new symptoms, isolation of potentially contagious residents, hand hygiene, COVID-19 policy regarding symptoms and testing, and personal protective equipment. As of this time, 83% of the entire staff had received the in-service training with the remainder of the staff receiving the education prior to the start of their next shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 26 of 27 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Prophetstown 310 Mosher Drive Prophetstown, IL 61277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer immunizations for residents who requested them for 2 of 5 residents (R54,R61) reviewed for immunizations in the sample of 17. Residents Affected - Few The findings include: 1) R54's electronic face sheet printed on 8/31/23 showed R54 was admitted to the facility on [DATE]. R54's document titled, Authorization and Release for Influenza Vaccine dated 10/17/22 showed R54 consented to receive the influenza vaccine. R54's physician's orders for October 2022 showed no order for R54 to receive the influenza vaccine. R54's medication administration record for October 2022 showed no documentation that R54 received the influenza vaccine. On 8/30/23 at 1:11PM, V2 (Director of Nursing) stated, Residents are offered the influenza, pneumococcal, and COVID-19 vaccinations upon admission to the facility if they have not already received them. Once the resident consents, we can administer the vaccination to them or arrange for them to get them through their physician. It is important to ensure our residents have access to the vaccinations they choose to receive to help prevent any illnesses. The facility's policy titled, Influenza Vaccine dated 2020 showed, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. 2) R61's electronic face sheet printed on 8/31/23 showed R61 was admitted to the facility on [DATE]. R61's document titled, Authorization and Release for Pneumococcal Vaccine dated 5/19/23 showed R61 consented to receive the PPSV23 vaccine. R61's physician's orders for May 2023 showed no order for R61 to receive the pneumonia vaccine. R61's medication administration record for May 2023 showed no documentation that R61 received the pneumonia vaccine. The facility's policy titled, Pneumococcal Vaccine dated August 2022 showed, All residents will be offered the pneumococcal vaccine to aide in preventing pneumonia/pneumococcal infections. 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145920 If continuation sheet Page 27 of 27