Allure of Prophetstown

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from missing narcotic medication for 1 of 3 residents (R1) reviewed for misappropriation of resident medication in the sample of 3. The past non-compliance occurred from 10/18/25- 10/20/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled narcotic medications were counted by the nursing staff for 1 of 3 residents (R1) reviewed for narcotic medications in the sample of 3. The past non-compliance occurred from 10/18/25 to 10/20/25.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe transfer for R1. This failure resulted in a laceration to R1's leg on 10/31/25 that required 9 stitches at the local emergency room for 1 of 3 residents (R1) reviewed for safe transfers in the sample of four. This past noncompliance occurred from 10/31/25 to 11/3/25.

Inspectors wroteBased on interview and record review, the Certified Nursing Assistant/CNA failed to notify the nurse when she saw a laceration to a resident's leg, which was a change in condition for 1 of 3 residents (R1) reviewed for change in condition in the sample of four. This past noncompliance occurred from 10/31/25 to 11/3/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure bedtime snacks were offered every evening for five residents (R22, R29, R31, R42, R59) of five residents in attendance in a group meeting in the sample of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent cross contamination by not ensuring staff wore the appropriate personal protective equipment (PPE) when entering the room of a covid positive resident (R34) and failed to perform hand hygiene after exiting R34's room or prior to entering other resident rooms on the unit. This failure affects 18 of 18 residents (R3, R4, R6, R12, R14, R16, R18, R23, R25, R34, R35, R37, R38, R46, R54, R57, R60, R61) reviewed for infection control in the sample of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately monitor daily meal and/or supplemental intakes for a resident (R3) with a significant weight loss. This failure affects 1 of 2 residents (R3) reviewed for nutrition in the sample of 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an adequate justification for the use of an antipsychotic medication in one resident (R2) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 41.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to document the administration of controlled medications for 1 of 3 residents (R3) reviewed for controlled medication in the sample of 3.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to transfer a resident in a safe manner, failed to follow facilty's policy and procedures for 1 of 3 residents (R1) in the sample of 3.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of Abuse within 24 hours to the state agency. This applies to 1 of 5 residents (R9) reviewed for abuse in the sample of 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system in place to track or trend illnesses, failed to have a process in place to identify contagious residents, and failed to implement transmission-based precautions for resident exhibiting infectious illness. These failures resulted in 9 residents (R1,R8,R16,R22,R35,R45,R47,R54,R61) experiencing respiratory illness, 17 residents (R4,R10,R11,R13,R17,R18,R19,R21,R29,R33,R46,R50,R51,R53,R58,R59,R62) testing positive for COVID-19, and 3 residents (R4,R50,R58) being hospitalized for COVID-19. The Immediate Jeopardy began on 8/26/23 when R22 and R45 began having symptoms of body pains, increased cough, and elevated temperatures. V1 (Administrator) and V3 (Regional Nurse) were notified of the Immediate Jeopardy on 8/31/23 at 1:47PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent severe, unplanned weight loss (R59) and failed to implement a nutritional supplement (R1) for 2 of 2 residents reviewed for nutrition in the sample of 17. These failures resulted in R59 sustaining a 21.36 % weight loss over 5 months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the services of a dietary manager. This has the potential to affect all residents in the building.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food storage and preparation areas were clean and free of insects. This applies to all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve pureed foods per the recipe guidelines for 5 of 5 residents reviewed for pureed foods. This applies to 2 residents (R3,R59) in the sample of 17 and 3 residents (R14,R25,R26) outside of the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a dressing in place over a recent surgical wound as ordered (R166) and failed to do daily weights as ordered (R16) for 2 of 2 residents reviewed for quality of care in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician prescribed treatments were in place for a resident with an unstageable wound (R62) and failed to ensure pressure ulcer interventions were in place for a resident at risk for wound development (R166) for 2 of 4 residents reviewed for pressure ulcers in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions to prevent a resident from falling for 1 of 7 residents (R59) reviewed for falls in the sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's oxygen tubing was changed weekly and failed to ensure a resident's oxygen was on during administration for 3 of 4 resident's reviewed for oxygen in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to administer immunizations for residents who requested them for 2 of 5 residents (R54,R61) reviewed for immunizations in the sample of 17.