Inspection visit
Inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 identify, assess, and implement treatment for a
pressure ulcer before developing into a stage three pressure ulcer for 1 of 6 residents (R6) reviewed for
pressure ulcers in the sample of 17.
Residents Affected - Few
The findings include:
On 8/5/24 at 10:25 AM, V12 (Wound Licensed Practical Nurse) performed a dressing change to R6's
pressure wound to her left buttock. V12 removed the dressing and R6 had a pressure ulcer present
measuring 2.6 centimeters (cm) x 1.8 cm x 0.1 cm.
R6's Weekly Skin assessment dated [DATE] shows that she has discolored excoriation to her left buttock
area.
R6's Shower Assessment Sheet dated 7/17/24 shows a circle around her buttock area and it documents,
ointment on. On 8/7/24 at 9:07 AM, V15 (Certified Nursing Assistant/CNA) said that she was the CNA that
filled out the shower sheet on 7/17/24. V15 said that she circled the buttocks area because there was a
dressing on her buttock and wrote ointment on because there was redness around the dressing that she
put ointment on.
R6's Wound Observation Tool dated 7/19/24 shows that a stage 3 pressure ulcer on her left buttock was
identified that measured 1.5 cm x 2 cm x 0.2 cm. No other assessment of the pressure wound were
provided prior to 7/19/24.
On 8/7/24 at 9:05 AM, V12 said that she saw the open pressure ulcer when she toileted R6 on 7/19/24. V12
said that when she saw it, it was a stage three open pressure ulcer. V12 said that the staff should have told
her about the open wound once it happened but no one notified her. V12 said that when the wound was
found, she asked the staff why no one reported it to her and she said that every one said that they thought
that she already knew about it.
The facility's undated Pressure Injury Prevention and Management Policy shows, Licensed nurses will
conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any
newly identified pressure injury. Findings will be documented in the medical record .Nursing assistants will
inspect skin during bath and will report any concern to the resident's nurse immediately after the task.
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 9
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
08/07/2024
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**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 splints were applied to
bilateral upper extremity contractures for 1 of 1 resident (R28) reviewed for splints in the sample of 17.
The findings include:
R28's Physician's Order Sheet printed on 8/6/24 shows an order dated 9/20/23 for: Resident to wear
bilateral WHO's (Wrist Hand Orthotics) daily, on at AM and off at HS (bedtime).
R28's Care Plan shows diagnoses of: spastic quadriplegic cerebral palsy, osteoarthritis and mild intellectual
disability.
R28's Minimum Data Set assessment dated [DATE] shows that she is dependent on staff for activities of
daily living, has impairment to both sides of her upper and lower extremities and received no days of splint
or brace assistance in the last 7 days.
On 8/5/24 at 10:58 AM, R28 was sitting in the common area of the facility in a high back wheelchair. R28
had bilateral contractures to her hand, wrist and arm. At 11:05 AM, there was a blue hand splint laying on
the floor near her garbage can in her room. At 1:16 PM, R28 did not have any splints on her upper
extremities.
On 8/6/24 at 9:20 AM and 1:26 PM, R28 was laying in bed. R28 did not have splints on her bilateral upper
extremities. R28's blue splint was still laying on the floor next to her garbage can.
On 8/6/24 at 1:26 PM, V17 (Restorative Certified Nursing Assistant) said that R28 does have bilateral hand
splints that she uses. V17 said that she applies them daily if the resident wants them on but does not
document their application, removal or refusal anywhere.
R28's Care Plan does not address when splints should be applied.
The facility's Prevention of Decline in Range of Motion Policy dated 7/1/23 shows, The facility will provide
treatment and care in accordance with professional standards of practice. This includes .appropriate
equipment (braces or splints) .Care Plan interventions will be developed and delivered through the facility's
restorative program .Interventions will be documented on the resident's person centered care plan.
Documentation should include, but not limited to: type of treatments, frequency and duration of treatments,
measurable objectives, resident goals. A nurse with responsibility for the resident will monitor for consistent
implementation of the care plan interventions. Refusals of care or problems associated with range of motion
exercises will be documented in the medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145920
If continuation sheet
Page 2 of 9
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
08/07/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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 water temperatures in resident
bathrooms were maintained at a safe level and failed to ensure fall precautions were implemented for
residents with a history of falling. These failures apply to 4 of 17 residents (R36, R31, R9, and R53)
reviewed for safety and supervision in the sample of 17.
The findings include:
1. On 8/5/24 at 10:57 AM, surveyor, using a calibrated thermometer, checked the water temperatures in
R53's bathroom sink which was 123.8 degrees Fahrenheit (F). On 8/5/24 at 11:02 AM, R31's bathroom sink
water temperature was 134.4 degrees F and on 8/5/24 at 2:05 PM, R9's bathroom water temperature was
125.1 degrees F.
On 8/5/24 at 10:59 AM, V3 (Certified Nursing Assistant/CNA) said some resident bathroom water
temperatures get so hot you can't even touch them. V3 said R31's bathroom was such a room. V3 said he
has informed maintenance about the concern with no response.
On 8/5/24 at 12:19 PM, V4 (Maintenance Director) said the water should be between 100 and 110 degrees
F, no more and no less; anything greater than 110 degrees can be scalding.
On 8/5/24 at 12:38 PM, V5 (Maintenance Assistant) was checking the water temperature in R31's room. As
the water was running steam was visible. V5 said, I can see it's hot, I can't even hold my hand under it. V5
said the temperature is 136 (degrees F) and going up.
The facility's Safe Water Temperatures Policy (undated) shows the following: It is the policy of this facility to
maintain appropriate water temperatures in resident care areas. Water temperatures will be set to a
temperature of no more than 100-110 degrees F.
2. On 8/5/24 at 10:37 AM, R53 propelled herself from the dining room to the bathroom in her room and
transferred herself onto the commode. R53 had bare feet.
On 8/5/24 at 10:43 AM, V11 (CNA) entered R53's bathroom, stood by R53 as R53 transferred back to her
wheelchair. V11 did not use a gait belt to assist R53.
R53's admission Record dated 8/6/24 shows her diagnoses include, but are not limited to, lack of
coordination, unsteadiness on feet, abnormalities of gait and mobility, need for assistance with personal
care, and history of falling.
R53's MDS (Minimum Data Set) dated 6/12/24 shows R53 has severe cognitive impairment and requires
substantial/maximal assistance with sit to stand, chair/bed to chair transfer, and toilet transfer.
R53's current care plan provided by the facility shows R53 has fallen six times in the last year. R53 needs
staff assistance prior to transfers and staff are to ensure R53 wears non-skid footwear.
3. On 8/5/24 at 10:25 AM, R36 was in the dining room doing activities. R36 kept standing up on her own.
V11 (CNA) walked with R36 out of the dining room. V11 did not use a gait belt when ambulating
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145920
If continuation sheet
Page 3 of 9
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
08/07/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
with R36. R36 had a shuffling, unsteady gait and her head was always looking down. At 10:29 AM, V11
walked back into the dining room with R36 and still no gait belt was being used. On 8/5/24 at 11:31 AM,
R36 was walking around unassisted in the dining room. Activities staff, V12 (Wound Care Nurse), and V8
(Licensed Practical Nurse) all walked by R36 and no one intervened or assisted R36.
R36's admission Record dated 8/7/24 shows R36's diagnoses include, but are not limited to, dementia,
unsteadiness on feet, lack of coordination, and weakness.
R36's MDS dated [DATE] shows R36 requires partial/moderate assistance with sit to stand, chair/bed to
chair transfer, walk 10 feet, walk 50 feet with two turns, and walk 150 feet.
R36's current care plan provided by the facility shows R36 is a fall risk and has fallen nine times in the past
year.
On 8/7/24 at 10:07 AM, V3 (CNA) said R36 ambulates by herself and does not need a gait belt. V3 said
they sometimes use a gait belt when R53 transfers from her chair to the commode so they can hold onto it
while they clean/wipe her, but R53 is independent with transfers.
The facility's Use of Gait Belt Policy (undated) shows the following: It is the policy of this facility to use gait
belts wit residents that cannot independently ambulate or transfer for the purpose of safety.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145920
If continuation sheet
Page 4 of 9
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
08/07/2024
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)
F 0692
Provide enough food/fluids to maintain a resident's health.
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 received ice cream as
ordered for 1 of 3 residents (R6) reviewed nutrition in the sample of 17.
Residents Affected - Few
The findings include:
R6's Face Sheet shows that she admitted to the facility on [DATE].
R6's Physician's Order Sheet printed on 8/7/24 shows an order dated 7/31/24 for ice cream at lunch and
dinner for additional nutrition.
R6's Vitals Summary shows that on 7/9/24 she was 116.8 pounds and on 7/30/24 she was 109.8 pounds.
R6's Nutrition Note dated 7/31/24 shows, staff report poor appetite .try ice cream with lunch and dinner
On 8/5/24 at 11:35 AM, R6's noon meal was delivered to the table. R6 had pureed enchiladas, potatoes,
pureed carrots and pureed strawberry dessert. R6 was not provided ice cream. R6 did not consume any of
her meal. R6 left the dining room at 11:52 AM. On 8/6/24 at 11:46 AM, R6 was seen leaving the dining
room. V7 (Cook) said that R6 barely ate any of her meal and was not served ice cream.
On 8/6/24 at 11:50 AM, V6 (Dietary Manager) said that R6 should be served ice cream with lunch and
dinner and it is on her meal ticket. V13 (Cook) said that she just missed it today.
On 8/6/24 at 12:18 PM, V14 (Dietitian) said that she likes to order ice cream or pudding for residents who
are eating 50% or less and not maintaining weight to help reduce weight loss. V14 said that if ice cream is
ordered to help with nutrition, it should be give with the meal and should be given at the ordered meal.
R6's Care Plan shows that she has a nutritional problem or potential nutritional problem r/t (related to)
anorexia with interventions to: Provide and serve supplements as ordered .Ice cream lunch and dinner .
The facility's undated Weight Monitoring Policy shows, 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145920
If continuation sheet
Page 5 of 9
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
08/07/2024
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)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure the placement of a feeding tube was
checked prior to administering medications and enteral feeding for 1 of 1 resident (R35) reviewed for tube
feeding in the sample of 17.
The findings include:
R35's Hospital Notes dated 8/1/24 shows, [AGE] year old male with a history of dementia was recently
hospitalized .had undergone G-tube placement on 7/26/24 .patient was seen in the emergency room on
7/30/24 after patient pulled out tube leading to the dislodged G-tube which was replaced in ED He was sent
back to [emergency room] again last night after he pulled the G-tube leading to dislodgment where the
balloon was outside the gastric lumen based on the CT imaging
On 8/6/24 at 9:00 AM, V18 (Registered Nurse) prepared R35's morning medications to administer via his
Percutaneous Endoscopic Gastrostomy (PEG) tube. V18 entered R35's room, opened the feeding tube
port, attached a syringe without a plunger into the tube feeding port and administered water, medications,
and 8 ounces of enteral feeding. V18 did not check placement of the feeding tube prior to administering.
On 8/6/24 at 2:21 PM, V2 (Director of Nursing) said that placement of a PEG tube should always be
checked before administering any tube feeding or medications to ensure that the tube is in the correct
place. V2 said that placement should be check by aspirating gastric content using a syringe.
The facility's Enteral Tube Feeding via Gravity Bag Policy revised on 11/23 shows, Verify placement of
feeding tube. If anything suggests improper tube positioning, do not administer feeding or medication .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145920
If continuation sheet
Page 6 of 9
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
08/07/2024
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)
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure a resident's bilateral under
arm pain was assessed, the physician notified, and treatment interventions implemented for 1 of 4
residents (R2) reviewed for pain in the sample of 17.
Residents Affected - Few
The findings include:
On 8/5/24 at 2:10 PM, R2 said that he has been having pain under both of his arms in his armpit area for
about a week. At that time, V12 (Wound Licensed Practical Nurse) entered the room. R2 explained the pain
to V12. V12 said that he probably had skin tags and she will have the nurse practitioner see him. On 8/6/24
at 1:49 PM, R2 said that he is still having the armpit pain and no one has done anything about it or even
looked at them. R2's armpits were observed. There were no skin tags present or any redness observed.
On 8/6/24 at 1:53 PM, V18 (Registered Nurse) was asked if she had heard anything about R2 having
bilateral armpit pain. V18 said that R2 is always complaining about some type of pain but she had not heard
that he was having armpit pain.
R2's Progress Notes from 8/1/24-8/7/24 do not document any assessments of his bilateral armpit pain. R2's
Medication Administration notes show that he received pain medication on 8/2/24 at 3:18 PM and 8/3/24 at
7:56 AM but did not document the location of the pain.
On 8/6/24 at 2:21 PM, V2 (Director of Nursing) said that if a resident is complaining of pain, the nurse
should go and assess the resident to identify where the pain is at, what makes it better, what makes it
worse and do a visual assessment to see if there is any observable signs of an issues. V2 said that if it is a
new pain for the resident, the physician should be notified and orders carried out if provided with new
orders. V2 said that the nurse should document their assessment of the pain in the resident's medical
record.
The facility's undated Pain Management Policy shows, Based on professional standards of practice an
assessment or evaluation of pain by the appropriate members of the interdisciplinary team may necessitate
gathering the following information, as applicable to the resident: history of pain and its treatment
.Identifying key characteristics of the pain: duration of pain, frequency, location, timing, pattern, radiation of
pain . Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other
health care professionals and the resident and/or resident's representative will develop, implement, monitor
and revise as necessary interventions to prevent or manager each individual resident's pain beginning at
admission
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145920
If continuation sheet
Page 7 of 9
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
08/07/2024
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review the facility failed to ensure multidose medication vials
were marked with expiration dates after opening which applies to 58 residents in the facility.
The findings include:
The CMS-671 form dated 8/5/24 showed the facility's census to be 58 residents.
On 8/7/24 at 10:35 AM, V9 (Licensed Practical Nurse) opened the medication room and medication storage
refrigerator. The 2 opened vials of Tuberculin testing solution were stored in the refrigerator. The first vial
was almost empty, and the second vial was approximately half empty. Both vials had no written opened
date or expiration date on them.
On 8/7/24 at 10:40 AM, V9 stated when the vials are opened the nurse should write the date on them. The
opened date will determine the expiration date. V9 stated Tuberculin is good for about a month after
opened.
On 8/7/24 at 12:00 PM, V2 (Director of Nursing) stated multidose vials need to have the date it was opened
written on them.
The facilities Medication Expired Dates and Storage Sheet (initialed 8/7/24) showed
Aplisol/Tubersol-Tuberculin PPD/Mantoux Injection- Should be maintained according to manufacture
recommendations in refrigerator. Expires 30 days after opening. Nurses write on the product the open and
expire dates.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145920
If continuation sheet
Page 8 of 9
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
08/07/2024
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)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview, and record review the facility failed to follow the pureed menu for 6 of 6
residents (R4, R6, R11, R23, R43 and R51) reviewed for dietary services in the sample of 17.
Residents Affected - Some
The findings include:
A facility provided list indicated R4, R6, R11, R23, R43, and R51 were on a pureed diet on 8/5/24.
The menu for 8/5/24 showed pureed enchiladas were to be served and a number 6 scoop providing a 5.33
ounce (oz.) serving size was to be used to plate the enchiladas.
On 8/5/24 11:26 AM, V7 (Cook) said there were 6 residents on a pureed diet. V7 started plating the pureed
food. V7 used a spoodle with a green handle to plate the pureed enchilada. Written on the handle of the
spoodle was 4 oz. V7 placed one 4 oz. scoop of the pureed enchiladas on the plates (1.33 oz. less than
what the menue called for).
On 8/5/24 at 12:08 PM, V7 said she was done plating the pureed food and used the 4 oz. spoodle to plate
the pureed enchiladas.
On 8/5/24 at 12:08 PM, after serving the pureed meals, there was pureed enchiladas in the serving
container covering the bottom of the container.
On 8/5/24 at 12:12 PM, V6 (Dietary Manager) said a number 6 scoop would provid 5.33 oz. and the menus
should be followed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145920
If continuation sheet
Page 9 of 9
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
12 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the August 7, 2024 survey of ALLURE OF PROPHETSTOWN?
This was a inspection survey of ALLURE OF PROPHETSTOWN on August 7, 2024. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALLURE OF PROPHETSTOWN on August 7, 2024?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.