Inspection·July 31, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 master count of controlled substances was maintained. This failure resulted in a resident's controlled medication to be missing for 1 of 3 residents (R1) reviewed for controlled medication counts. This past non-compliance occurred form 7/13/24 to 7/18/24. Residents Affected - Few The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including other chronic pain, and fibromyalgia. The 7/31/24 order summary sheet for R1 shows an order for hydrocodone-acetaminophen tablet 5-325 mg (Norco) , 1 tablet to be given every morning and at bedtime for pain. R1's progress notes show on 7/11/24 at 4:00 PM, she was sent out and admitted to the hospital and returned on 7/15/24 at 4:00 PM. On 7/31/24 at 10:50 AM, V4 LPN (Licensed Practical Nurse) said on 7/11/24 she gave R1 her morning dose of Norco and then later in the shift, sent her out to the hospital. The Norco was in the cart at the end of the shift count. She said when R1 returned from the hospital on 7/15/24, she noted the Norco missing from the medication cart. V4 said she was not sure what had happened to it, and followed up on 7/16/24 with the pharmacy and the DON (Director of Nursing) to see if the completed narcotic sheet had been turned into her. She said once she reported it, the medication room was searched and both medication carts and the Norco was no where to be found. She reported the missing medication to the administrator. V4 said, at the time of the missing Norco, there was no master count of the narcotics and the only way to know if a medication was missing would be the nurses knowing what should be in there. On 7/31/24 at 10:33 AM, V6 RN (Registered Nurse) said she worked on 7/11/24 and had punched out R1's medications on accident, after realizing R1 was in the hospital. She wasted the Norco with the other nurse on duty, so she knows the card was present and accounted for during her shift and reporting off on 7/12/24 at 6:00 AM. On 7/31/24 at 9:45 AM, V5 RN said R1 was on a scheduled Norco twice daily and should have had a card in the cart. V5 said R1 went to the hospital on 7/11/24 and was not working that day, but did notice on the narcotic count on 7/13/24, R1's Norco was not in the drawer. V5 said she asked V3 RN during the count about R1's card and she did not have any answer. V5 said V3 was an agency nurse and was not familiar with her. She noticed the Norco was gone along with the count sheet. V5 said R1 remained in the hospital, so she continued the count. When R1 returned on 7/15/24, there still was no Norco (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 3 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 07/31/2024 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)