Inspection·March 26, 2024

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 ensure resident safety by not using a gait belt during a transfer and pushing a resident in a wheelchair without footrests for 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 3. The findings include: R2's face sheet showed an [AGE] year-old male with diagnosis of Parkinson's Disease, dementia, orthostatic hypotension, weakness, and repeated falls. On 3/26/24 ay 8:37 AM, V5 Certified Nursing Assistant (CNA) pushed R2 down the hallway in a wheelchair. There were no footrests on the wheelchair. At 8:39 AM, R2 was seated on the toilet in his room. There was a gait belt hanging on the inside of the bathroom door which was open. There was a pad alarm in R2's wheelchair. R2 did not have a gait belt on his waist. V5 assisted R2 to a standing position and assisted him to sit in the wheelchair without using a gait belt. There was a white dressing to R2's left leg just below the knee. V2 Assistant Director of Nursing (ADON) entered the room and checked R2's dressing. V2 witnessed the transfer and did not intervene. On 3/26/24 at 8:40 AM, V5 said after toileting, she will take R2 to the common area for activities since he has an alarm. The alarm means he is a fall risk and he fell in the dining room recently. At 8:40 AM, R2 said he fell 3 years ago. At 8:44 AM, V2 Nurse Manager said R2 had a blister-like lesion to the left leg when he was admitted . It opened after his recent fall and the dressing is changed every Monday, Wednesday and Friday. V2 said she saw the transfer without the gait belt, and it should have been used. V2 said R2 was a fall risk and had 3 falls since admission. At 10:33, V10 Director of Therapy said leg rests are recommended on wheelchairs when staff are pushing the. If they are not on, the resident could drop their foot and fly forward out of the chair. It's a potentially unsafe practice not to use them. R2 was not evaluated by therapy as he was admitted on hospice. At 10:40 AM, V7 Licensed Practical Nurse (LPN) said a gait belt should be used to transfer R2. Wheelchairs should have footrests on when staff are moving residents. It's for resident safety. We need to keep them as safe as possible. If they aren't on, the resident could put their feet down and go flying headfirst onto the floor. I've seen it happen. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145920 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 03/26/2024 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)