Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allure Of Prophetstown during CMS and state inspections, most recent first.
A resident on hospice care with a physician order for Morphine Sulfate did not receive any doses, and both the medication bottle and count sheet went missing. An LPN noticed the unusual appearance of the Morphine and later found it, along with the count sheet, missing and not signed out on the master count sheet. The DON's investigation, including review of video footage and staff interviews, determined that a nurse had taken the Morphine, resulting in misappropriation of the resident's medication.
A resident on hospice care with a physician order for Morphine Sulfate had a bottle of the medication and its count sheet go missing, with no doses recorded as given. Nursing staff failed to consistently perform and document required shift change counts of controlled substances, resulting in gaps in the medication count process and the loss of the narcotic medication and its documentation.
A resident with significant mobility and medical needs was transferred by two CNAs without the required use of a gait belt or proper assistance, resulting in the resident striking her leg on a wheelchair and sustaining a deep laceration that required stitches. The transfer did not follow the care plan, and the incident was not promptly reported to nursing staff.
A CNA failed to notify a nurse after discovering a deep laceration on a resident's leg during a transfer, instead covering the wound and continuing care without reporting the injury. The resident, who was dependent for transfers and had multiple medical conditions, was later found by another staff member and sent to the ER for sutures. Facility policy requires immediate notification of such changes in condition, but the CNA stated she forgot to inform the nurse after becoming distracted by other duties.
A facility failed to consistently offer bedtime snacks to five residents who reported that evening snacks were not always provided. Dietary staff passed out snacks to the 200 and 300 units, but only documented when a resident took a snack, not refusals, and the snack logs were kept in the kitchen rather than the resident record. Review of snack logs showed inconsistent and incomplete documentation, including entire days with no entries.
A Laundry Aide entered a resident’s room after the resident was identified as COVID positive without hand hygiene or the required PPE, then exited and continued entering other resident rooms while distributing laundry. The resident was on strict droplet and contact isolation, and the facility’s infection control guidance required hand hygiene and full PPE use for room entry and exit. The IP stated staff should have worn a gown, N95 mask, and gloves and performed hand hygiene to prevent cross contamination.
Failure to monitor meal and supplement intake for a resident with significant weight loss. A resident with Parkinson's disease, dementia, and malnutrition had repeated meal refusals and 0-50% intake documented, with several meals left undocumented. Staff observed the resident refusing meals while no encouragement was provided, and the DON stated there was no clear way to track how much food was eaten versus supplements. The resident had multiple nutrition orders and was flagged for BMI, but the facility had no further documentation addressing the weight loss.
Inadequate justification for antipsychotic use: A resident with dementia and psychiatric diagnoses received Quetiapine 50 mg BID, but the record lacked care plan documentation for the medication, target behaviors, or non-pharmacological interventions. The psych note stated the resident no longer met criteria for Schizoaffective Disorder and instead had dementia-related psychotic disturbance, while behavior monitoring showed only one day of abusive language and no other behaviors. The DON acknowledged the behaviors were not severe or prolonged.
The facility failed to label multidose medication vials with expiration dates after opening, affecting 58 residents. An LPN was observed storing two opened vials of Tuberculin testing solution without written opened or expiration dates. The LPN and DON acknowledged the requirement to mark vials with the opened date to determine expiration, as Tuberculin is viable for about a month after opening. The facility's policy mandates writing open and expire dates on such products.
The facility failed to maintain safe water temperatures in resident bathrooms, with temperatures recorded significantly above the safe range, reaching up to 136 degrees Fahrenheit. Additionally, the facility did not implement adequate fall precautions for residents with a history of falling. One resident with severe cognitive impairment was observed transferring herself without assistance or a gait belt, and another resident, a fall risk, was seen ambulating unassisted without a gait belt, despite needing moderate assistance.
The facility did not follow the prescribed pureed menu for six residents on a pureed diet. The menu required a 5.33-ounce serving of pureed enchiladas using a number 6 scoop, but the cook used a 4-ounce spoodle, resulting in insufficient portion sizes. This was confirmed by the Dietary Manager, and leftover food in the serving container indicated incorrect portioning.
A resident developed a stage three pressure ulcer due to the facility's failure to identify, assess, and treat the wound in a timely manner. Despite existing protocols, staff did not report the wound to the Wound LPN, assuming she was already aware, which delayed treatment and allowed the ulcer to worsen.
A facility failed to apply and document the use of splints for a resident with spastic quadriplegic cerebral palsy, as prescribed. The resident was observed without her wrist-hand orthotics (WHO's) on multiple occasions, and one splint was found on the floor. The care plan lacked specific instructions for splint application, and the Restorative CNA did not document their use or refusal, contrary to the facility's policy.
A resident with significant weight loss was not provided ice cream as ordered for nutritional supplementation. Despite a physician's order and care plan interventions, the resident did not receive ice cream with meals on two observed occasions. Staff interviews confirmed the oversight, and the facility's weight monitoring policy emphasized the need for consistent interventions to maintain nutritional status.
A resident with dementia and a history of dislodging his PEG tube received medications and enteral feeding without prior verification of tube placement. A nurse administered these through the tube without checking its position, contrary to the facility's policy. The Director of Nursing confirmed that placement should be verified by aspirating gastric content.
A resident experienced bilateral underarm pain for about a week without proper assessment or physician notification. Despite complaints, no follow-up occurred after an LPN suggested skin tags, and the RN was unaware of the specific pain. Progress notes lacked documentation of the pain assessment, and while pain medication was given, the location was not recorded. The DON stated that pain complaints should be assessed, documented, and communicated to the physician, as per the facility's Pain Management Policy.
A resident's controlled medication went missing due to the facility's failure to maintain a master count of narcotics. The resident, with chronic pain and fibromyalgia, was sent to the hospital, and upon return, the medication was unaccounted for. Staff interviews and security footage suggested an agency nurse might have taken the medication and count sheet, highlighting a lapse in the facility's policy on reporting misappropriation.
A resident with dementia and a recent hip fracture received Norco for pain, but the LPN failed to document most doses on the MAR. Despite signing out 18 pills over two months, only 2 doses were recorded. The facility's policy requires documentation of medication administration, which was not followed.
A resident with severe cognitive impairment fell and sustained a head laceration, but the incident was not documented in the progress notes. The facility's staff acknowledged the omission, which violated the policy requiring documentation of falls, injuries, and notifications.
A resident with severe cognitive impairment fell and sustained a head injury during a transfer when a CNA attempted to use a mechanical lift alone, contrary to facility policy requiring two staff members. The resident, known to lean forward during transfers, was not adequately supervised, leading to the fall and subsequent hospital transfer.
Misappropriation of Controlled Substance for Hospice Resident
Penalty
Summary
A resident was admitted to the facility and placed on hospice care, with a physician order for Morphine Sulfate to be administered as needed for pain or shortness of breath. The controlled substance record indicated that a 5ml bottle of Morphine Sulfate was received for the resident, but the Medication Administration Record showed that no doses were administered and the resident had no complaints of pain. A nurse noticed that the Morphine bottle appeared unusual, with a thick gel and pink color, and later discovered that both the bottle and the count sheet were missing. The count sheet was later found intact in the shred bin, with no doses signed out, and the master count sheet did not reflect the medication being signed out. The Director of Nursing conducted a review, including video footage of shift change narcotic counts, and determined that the bottle and count sheet were last seen during a morning count between two nurses. The subsequent shift change was not visible on camera, and the nurse who participated in the count did not recall seeing the Morphine bottle. Based on these findings, it was determined that a nurse had taken the bottle of Morphine, resulting in the misappropriation of the resident's medication. The facility's policy defines misappropriation as the deliberate misplacement or wrongful use of a resident's property without consent.
Failure to Properly Count and Document Controlled Narcotic Medication
Penalty
Summary
The facility failed to ensure that controlled narcotic medications were properly counted and documented by nursing staff for one resident who was admitted on hospice care and had a physician order for Morphine Sulfate. The resident's controlled substance record indicated that a 5ml bottle of Morphine Sulfate was received, but no doses were administered according to the medication sheet. Subsequently, the bottle and its count sheet went missing, and there was no record of the medication being signed out on the master count sheet. Interviews with nursing staff revealed that the required shift change counts of controlled substances were not consistently performed or documented, with several shift changes lacking any recorded counts for the medication cart. The Director of Nursing confirmed that the bottle and count sheet were last seen during a morning count and later found the count sheet in the shred bin, still intact and unsigned for any doses. Further review of the facility's procedures and interviews with staff indicated that the process for counting and documenting controlled substances at shift change was not followed as required. The facility's policy mandates that two licensed nurses account for all controlled substances at the end of each shift, but gaps in documentation and missing counts were identified. The failure to perform and document the narcotic counts as required led to the loss of the Morphine Sulfate bottle and its associated count sheet, with no explanation or record of its disposition.
Failure to Provide Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including metabolic encephalopathy, gastrointestinal hemorrhage, and limited mobility, was not safely transferred by staff. The resident's care plan required assistance from two staff members for pivot transfers using a front wheeled walker (FWW) and gait belt, with staff responsible for blocking the resident's feet and providing verbal cues due to visual deficits. Despite these requirements, the resident was transferred without a gait belt, and the transfer was not performed according to the care plan instructions. During the incident, two CNAs were involved in transferring the resident to a recliner. The resident reported that the staff did not use a gait belt and did not provide adequate assistance, resulting in her missing part of the wheelchair seat and striking her leg on the wheelchair, causing a deep laceration that required nine stitches. Blood was later found on the foot pedal pegs of the wheelchair, supporting the conclusion that the injury occurred during the unsafe transfer. The resident expressed that she did not feel safe during the transfer and had not previously met the staff involved. Interviews and record reviews revealed inconsistencies in staff accounts, with one CNA stating she used a sit-to-stand lift by herself and another indicating the resident refused to transfer with a gait belt. The investigation determined that the staff failed to follow the resident's care plan and facility policy for safe transfers, including the use of a gait belt and ensuring proper clearance from wheelchair components. The incident was not immediately reported to nursing staff, and the resident's complaints of pain were not promptly addressed.
Failure to Notify Nurse of Resident Laceration Following Transfer
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to notify a nurse after discovering a laceration on a resident's leg, which constituted a change in the resident's condition. The resident, who had multiple diagnoses including metabolic encephalopathy, gastrointestinal hemorrhage, and bullous pemphigoid, was dependent for transfers and toileting. The incident began when the CNA observed the resident's leg was bleeding, covered the wound with a towel, and proceeded to assist the resident with toileting. The CNA did not immediately inform the nurse about the injury, stating later that she became distracted by answering other call lights and forgot to report the incident. The deficiency was identified when another CNA responded to the resident's call light and noticed the laceration, prompting nurse intervention. Documentation showed that the resident was later sent to the emergency room, where she received nine stitches for the deep laceration. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, confirmed that the CNA had not reported the injury as required by facility policy, which mandates prompt notification of changes in resident condition, including injuries that may require physician intervention. Further investigation, including review of facility camera footage and staff interviews, indicated that the injury likely occurred during a transfer performed by the CNA. The CNA admitted to covering the wound and not reporting it immediately due to fear of getting in trouble and being distracted by other duties. The failure to promptly notify nursing staff delayed appropriate assessment and intervention for the resident's injury.
Inconsistent Offering and Documentation of Bedtime Snacks
Penalty
Summary
The facility failed to ensure bedtime snacks were offered every evening for five residents who attended a group meeting and reported that evening snacks were not consistently offered or received. During the meeting, all five residents stated they did not consistently get offered snacks in the evening. One resident said staff bring in a big bowl with different snacks to choose from, but they are not always offered. Interview and record review showed Dietary staff were responsible for passing out evening snacks around 6:30 p.m. to the 200 and 300 units and documenting on a snack log only if a resident actually took a snack. The Evening Cook stated refusals were not documented, and the snack logs were kept in the kitchen rather than in the resident record. The DON stated CNAs did not really have anything to do with passing out evening snacks and did not document them because they did not pass them out. Review of the Evening Snack Logs for the 200 and 300 units during July, August, and September 2025 showed inconsistent and incomplete documentation, including entire days with no recordings of snacks taken or offered for the five residents.
Failure to Use PPE and Hand Hygiene for COVID-Positive Resident
Penalty
Summary
The facility failed to prevent cross contamination when staff did not use the required PPE and did not perform hand hygiene while caring for a resident with COVID-19. R34 was documented as COVID positive and placed on strict droplet and contact isolation with orders for care, treatments, activities, and meals to be provided in the resident’s private room. The resident’s room had contact and droplet precaution signage posted, and supplies including isolation gowns, K95 respirator masks, and gloves were available outside the room. During observation, a Laundry Aide entered R34’s room without performing hand hygiene and without putting on a K95 mask, gown, or gloves. The aide hung clothing items in the resident’s closet, exited the room without changing the surgical mask or performing hand hygiene, and then continued down the hall entering and exiting several other resident rooms while distributing laundry items. The aide stated he had been previously in-serviced on PPE use for isolation rooms, but said he did not think PPE was needed before entering R34’s room because he was only going in and out. The infection preventionist stated that because R34 was COVID positive, staff should have worn full PPE, including a gown, N95 mask, and gloves, and should have performed hand hygiene upon entering and exiting the room to prevent cross contamination. The facility’s infection control policies and precaution signs also stated that staff must clean their hands before entering and leaving rooms and use the appropriate PPE for contact, droplet, and airborne precautions. The deficiency affected 18 residents on the locked 100 unit who were reviewed for infection control.
Failure to Monitor Meal and Supplement Intake for Resident With Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor daily meal and supplemental intakes for a resident with significant weight loss. The resident had a history of Parkinson's disease, dementia, and mild-calorie protein malnutrition, and her documented weight decreased from 98.6 lbs. to 92.0 lbs. over six months. Her care plan identified impaired nutrition risk related to impaired cognition and behavioral symptoms, noted that she hears voices that tell her whether to eat, and included interventions such as meal assistance, offering Ensure when meals were refused, and encouraging nutritional supplements between meals. The resident's nutrition note documented a weight warning and significant weight loss, with supplements and fortified foods in place because of varied meal intake. During observations, the resident was seen sitting in bed with meal trays and a shake present, stated she did not want to eat, and no staff were observed encouraging her to consume food or drink. Staff interviews indicated the resident usually would not eat because voices told her not to eat, and the DON stated aides should document all meal intake, while dietary items such as yogurt, power potatoes, and super cereal should also be documented with meal intake. The DON also stated there was no clear-cut way to document or monitor what percentage of food was consumed versus the supplement. Record review showed repeated meal refusals or intake of 0-50% across multiple date ranges, with several meals lacking documentation of the amount eaten. The resident had active orders for Ready Care 2.0 three times daily, chocolate pudding twice daily between meals, ice cream twice daily, yogurt at breakfast, super cereal at breakfast, and power potatoes at lunch and dinner. The medical director had assessed the resident and flagged her for BMI, but the facility provided no further documentation addressing the significant weight loss. The dietitian stated the resident was on the nutrition at risk list and would meet weekly with management to discuss the plan of care.
Inadequate justification for antipsychotic use
Penalty
Summary
The facility failed to provide an adequate justification for the use of Quetiapine, an antipsychotic medication, for one resident with dementia and other psychiatric diagnoses. The resident was observed at different times appearing irritable and somnolent, then later well-dressed, pleasant, and easily engaged. The current physician order summary listed diagnoses including Dementia with Psychotic Disturbance, General Anxiety Disorder, and Major Depressive Disorder, and the resident was receiving Quetiapine 50 mg twice daily related to Dementia with Psychotic Disturbance. A psychotropic informed consent dated 5/10/22 documented consent for Seroquel 50 mg twice daily. The medication regimen review and prescriber response dated 11/8/24 indicated the resident was still disoriented at times, insisting she needed to go to school or get kids, and could be irritable at times, so the current dose was continued. However, a psychiatric services note dated 5/9/25 stated the resident no longer met criteria for Schizoaffective Disorder and that her dominant clinical presentation reflected dementia-related psychotic disturbance. The behavior monitoring record from 8/27/25 to 9/25/25 showed abusive language on one day and no behaviors on all other days. The resident’s care plan did not include documentation related to Seroquel, target behaviors, or non-pharmacological interventions. The DON stated the psychiatric physician determined the resident no longer met criteria for Schizoaffective Disorder and acknowledged the resident’s behaviors were not severe or prolonged.
Failure to Label Multidose Medication Vials with Expiration Dates
Penalty
Summary
The facility failed to ensure that multidose medication vials were marked with expiration dates after opening, affecting 58 residents. During an observation, a Licensed Practical Nurse (LPN) was found to have opened the medication room and storage refrigerator, where two opened vials of Tuberculin testing solution were stored. The first vial was almost empty, and the second vial was approximately half empty, with neither vial having a written opened date or expiration date. The LPN acknowledged that the opened date should be written on the vials to determine the expiration date, noting that Tuberculin is viable for about a month after opening. The Director of Nursing (DON) confirmed that multidose vials need to have the date they were opened written on them. The facility's Medication Expired Dates and Storage Sheet indicated that Tuberculin should be maintained according to manufacturer recommendations in the refrigerator and expires 30 days after opening, with nurses required to write the open and expire dates on the product.
Failure to Maintain Safe Water Temperatures and Implement Fall Precautions
Penalty
Summary
The facility failed to maintain safe water temperatures in resident bathrooms, with temperatures recorded significantly above the safe range of 100-110 degrees Fahrenheit. During the survey, water temperatures in the bathrooms of three residents were found to be excessively high, reaching up to 136 degrees Fahrenheit. A Certified Nursing Assistant (CNA) reported that some bathroom water temperatures were too hot to touch and had informed maintenance, but no action was taken. The Maintenance Director confirmed that water temperatures should not exceed 110 degrees Fahrenheit, acknowledging the risk of scalding. Additionally, the facility did not implement adequate fall precautions for residents with a history of falling. One resident, with severe cognitive impairment and a history of falls, was observed transferring herself without assistance or the use of a gait belt, contrary to her care plan requirements. Another resident, also a fall risk, was seen ambulating unassisted without a gait belt, despite needing moderate assistance according to her care plan. Staff members, including CNAs and nurses, failed to intervene or provide the necessary support, neglecting the facility's policy on the use of gait belts for residents who cannot independently ambulate or transfer.
Failure to Follow Prescribed Pureed Menu
Penalty
Summary
The facility failed to adhere to the prescribed pureed menu for six residents who were on a pureed diet. On the specified date, the menu indicated that pureed enchiladas were to be served using a number 6 scoop, which provides a 5.33-ounce serving size. However, the cook, identified as V7, used a spoodle with a green handle labeled as 4 ounces to plate the pureed enchiladas, resulting in a serving size that was 1.33 ounces less than required. This discrepancy was confirmed by the Dietary Manager, V6, who acknowledged that the menu should have been followed. Observations noted that after serving the meals, there was still pureed enchilada left in the serving container, indicating that the correct portion sizes were not served.
Failure to Identify and Treat Pressure Ulcer
Penalty
Summary
The facility failed to properly identify, assess, and implement treatment for a pressure ulcer, which resulted in the development of a stage three pressure ulcer for one resident. On a specific date, a Wound LPN performed a dressing change on the resident's left buttock, revealing a pressure ulcer measuring 2.6 cm x 1.8 cm x 0.1 cm. Prior assessments indicated discolored excoriation in the same area, and a shower assessment sheet noted redness and ointment application. However, no formal assessment of the pressure wound was documented until two days later, when a stage three pressure ulcer was identified. The Wound LPN reported discovering the open pressure ulcer during toileting and noted that staff failed to notify her of the wound's presence. The facility's policy requires licensed nurses to conduct full body skin assessments weekly and after any newly identified pressure injury, with findings documented in the medical record. Nursing assistants are also required to inspect skin during baths and report concerns immediately. Despite these protocols, the staff did not communicate the presence of the wound, assuming the Wound LPN was already aware, leading to a delay in appropriate treatment and escalation of the wound to a stage three pressure ulcer.
Failure to Apply and Document Use of Splints for Resident
Penalty
Summary
The facility failed to ensure that a resident's splints were applied to her bilateral upper extremity contractures as prescribed. The resident, who has spastic quadriplegic cerebral palsy, osteoarthritis, and mild intellectual disability, was observed multiple times without her prescribed wrist-hand orthotics (WHO's). The physician's order required the resident to wear these splints daily, but observations on consecutive days showed the resident without them, and one splint was found on the floor in her room. The resident's care plan did not specify when the splints should be applied, and the Restorative Certified Nursing Assistant (CNA) responsible for applying the splints stated that they were applied only if the resident wanted them on, with no documentation of their application, removal, or refusal. The facility's policy on the prevention of decline in range of motion required documentation of interventions, including the use of splints, but this was not followed. The lack of documentation and adherence to the care plan contributed to the deficiency.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to ensure that a resident received ice cream as ordered for nutritional supplementation. The resident, identified as R6, was admitted to the facility and had a physician's order dated 7/31/24 for ice cream to be provided at lunch and dinner to address her nutritional needs. R6's weight had decreased from 116.8 pounds on 7/9/24 to 109.8 pounds on 7/30/24, indicating a significant weight loss. Despite the order, observations on 8/5/24 and 8/6/24 revealed that R6 was not served ice cream with her meals, and she did not consume any of her meal on 8/5/24. Interviews with facility staff, including the cook and dietary manager, confirmed that R6 was not provided ice cream as ordered. The dietary manager acknowledged that ice cream should have been served with R6's meals, and the cook admitted to missing the order. The dietitian explained that ice cream is ordered for residents who are eating less than 50% of their meals and not maintaining weight, to help reduce weight loss. R6's care plan included interventions to provide and serve supplements, such as ice cream, as ordered. The facility's weight monitoring policy emphasized the need for interventions consistent with the resident's assessed needs and professional standards to maintain nutritional status.
Failure to Verify Feeding Tube Placement Before Administration
Penalty
Summary
The facility failed to ensure the proper checking of a feeding tube's placement before administering medications and enteral feeding to a resident. The resident, a male with a history of dementia, had a Percutaneous Endoscopic Gastrostomy (PEG) tube placed after a recent hospitalization. The resident had a history of pulling out the tube, leading to dislodgment and requiring replacement. On the morning of August 6, a registered nurse administered water, medications, and enteral feeding through the resident's PEG tube without verifying its placement. The Director of Nursing confirmed that the placement should be checked by aspirating gastric content before any administration, as per the facility's policy revised in November 2023.
Failure to Assess and Manage Resident's Armpit Pain
Penalty
Summary
The facility failed to provide appropriate pain management for a resident experiencing bilateral underarm pain. The resident reported having pain in the armpit area for about a week, but no assessment was conducted, and the physician was not notified. Despite the resident's complaints, the Wound LPN suggested the presence of skin tags and mentioned that a nurse practitioner would see the resident, but no follow-up occurred. The resident continued to experience pain without any intervention or assessment, and the RN was unaware of the resident's specific complaint of armpit pain. The resident's progress notes from the specified period did not document any assessments of the bilateral armpit pain, and while pain medication was administered, the location of the pain was not recorded. The Director of Nursing stated that the protocol for a resident complaining of pain includes assessing the pain, notifying the physician if it is new, and documenting the assessment in the medical record. The facility's Pain Management Policy outlines the need for a thorough assessment and collaboration with healthcare professionals to manage the resident's pain, which was not adhered to in this case.
Controlled Medication Mismanagement
Penalty
Summary
The facility failed to maintain a master count of controlled substances, resulting in the disappearance of a resident's controlled medication. The resident, who was admitted with multiple diagnoses including chronic pain and fibromyalgia, had an order for hydrocodone-acetaminophen to be administered twice daily. On the day the resident was sent to the hospital, the medication was accounted for at the end of the shift. However, upon the resident's return, the medication was missing from the cart. Interviews with staff revealed that there was no master count of narcotics, and the only way to identify missing medication was through the nurses' knowledge of what should be present. Further investigation showed discrepancies in the narcotic count sheets, with one less page turned in the count book during a shift change. Security footage and interviews suggested that an agency nurse, unfamiliar with the facility, may have taken the medication and the count sheet. The facility's policy on reporting misappropriation of resident property was not effectively implemented, leading to the wrongful use of the resident's belongings without consent.
Failure to Document Controlled Medication Administration
Penalty
Summary
The facility failed to properly document the administration of controlled medications for a resident, identified as R3, who was admitted with multiple diagnoses including dementia, Alzheimer's disease, and osteoarthritis, and later diagnosed with a fracture of the right femur. The deficiency was identified through observation, interview, and record review, revealing that the Licensed Practical Nurse (LPN), V9, administered Norco, a controlled medication, to R3 but failed to document the administration on the Medication Administration Record (MAR) for several doses. Specifically, between June and July 2024, V9 signed out a total of 18 pills but only documented the administration of 2 doses on the MAR. Interviews with the Director of Nursing (DON) and V9 confirmed that the facility's policy requires each medication to be documented on the MAR after administration, and PRN medications should have their effectiveness documented. V9 admitted to forgetting to document the medication administration despite claiming that all doses signed out were given to R3. Observations of R3 indicated she was alert but unable to communicate her pain levels due to confusion, and her husband noted she likely took pain medication to help with sleep following her hip surgery. The facility's policy mandates that medications be administered by licensed nurses and documented accordingly, which was not adhered to in this case.
Failure to Document Resident Fall and Assessment
Penalty
Summary
The facility failed to document a fall and subsequent assessment for a resident with severe cognitive impairment and multiple diagnoses, including unspecified dementia and expressive language disorder. The resident, who is dependent on staff for all activities of daily living, experienced a fall on 6/15/24, resulting in a head laceration and was sent to the emergency room for observation. However, the progress notes for that day did not document the incident, the assessment, or the time the resident was sent to the hospital. A neurological flow sheet indicated that vital signs and neuro checks were initiated at 2:45 PM, but the progress notes lacked any mention of the fall or the actions taken. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that the standard procedure for documenting falls was not followed. The staff acknowledged that the incident should have been recorded in the progress notes, including details of the fall, any injuries, and notifications made to relevant parties such as the physician, nurse practitioner, and power of attorney. The facility's policy on incidents and accidents requires documentation of the date, time, nature of the incident, and any immediate interventions, which was not adhered to in this case.
Failure to Safely Transfer Resident with Mechanical Lift
Penalty
Summary
The facility failed to transfer a resident safely, resulting in a fall and injury. The resident, who has severe cognitive impairment and is dependent on staff for transfers, was listed as requiring a mechanical lift with two staff assistance. However, on the day of the incident, a CNA attempted to transfer the resident alone using a mechanical lift. During the transfer, the resident began to lean forward, and despite the CNA's attempt to catch her, the resident fell out of the sling and hit her head on the floor, sustaining a laceration. Interviews with staff revealed that the resident is known to lean forward during transfers, necessitating the presence of two staff members for safety. The facility's policy also mandates that two staff members must be present when using a mechanical lift for transfers. However, the CNA did not seek assistance, and the incident occurred without the required second staff member present. The resident was subsequently taken to the hospital for evaluation of the head injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Prophetstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winning Wheels | 1 mi | ★★★★★ | 6 | 0 |
| Resthave Home-whiteside County | 8.7 mi | ★★★★★ | 8 | 0 |
| La Bella Of Morrison | 9.3 mi | ★★★★★ | 24 | 0 |
| Allure Of Sterling | 15.1 mi | ★★★★★ | 15 | 1 |
| Citadel Of Sterling,the | 15.4 mi | ★★★★★ | 0 | 0 |
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