Inspection·June 20, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 document a resident fall and assessment for 1 of 3 residents (R2) reviewed for falls in the sample of 3. Residents Affected - Few The findings include: R2's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including unspecified dementia, unspecified severity with psychotic disturbance, and expressive language disorder. The facility's 5/22/24 quarterly assessment shows R2 to have severe cognitive impairment and is rarely/never understood. The same assessment shows she is dependant upon staff for all of her ADL' (activities of daily living). The facility accident and incident log for June 2024 documents on 6/15/24, R2 had a fall and sustained a laceration to her head, was sent to the emergency room and admitted for observation. The progress notes for R2 were reviewed for 6/15/24 and show a note at 2:46 PM of behaviors such as yelling out and shouting from her room. The next progress note at 5:42 PM, the local hospital was called for an update on R2's condition. The notes do not show any incident, assessment, or when R2 was sent out to the hospital. A 6/15/24 neurological flow sheet shows vital signs and neuro checks were initiated at 2:45 PM. The history and physical reports from the emergency room documents R2 was seen on 6/15/24 at 3:41 PM following a fall out of her wheelchair. She was dizzy and fell striking her left forehead. She was assessed for head trauma. On 6/20/24 at 10:40 AM, V9 RN (Registered Nurse) said when a resident falls it should be documented in the progress notes what happened, and if/when an ambulance is called. An incident report is completed. She said when R2 fell, she had a skin tear to her right eye. She was working when the fall occurred and recalls someone yelling out for help. She found R2 lying on the floor with blood around her face. She had fallen out of the geriatric chair. V9 said she recalls initiating neuro checks because R2 had hit her head, and everything happened so fast, she did not document in the progress notes. V9 reviewed the progress notes and stated she should have made a note about the fall and her assessment. On 6/20/24 at 930 AM, V7 RN said when a resident falls, it is documented in the progress notes of what happened, and any notifications such as the DON (Director of Nursing), NP (Nurse Practitioner), and POA (Power of Attorney). In addition if the resident is sent out, it should be noted when 911 (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 4 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 06/20/2024 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)