Allure of Prophetstown

In the surveyor’s words

From the most serious findings on record at Allure of Prophetstown, in the surveyor’s own words.

• Immediate jeopardy, patternF880Sep 1, 2023

  Based 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. […]

• Actual harm, isolatedF689Aug 28, 2026

  Based on interview and record review, the facility failed to transfer a resident (R1) with a gait belt, and failed to supervise a resident (R1) during ambulation. These failures apply to 1 of 3 residents (R1) reviewed for safety & supervision in the sample of 4. These failures resulted in R1 obtaining a intertrochanteric fracture of her left hip and undergoing left femur intramedullary nailing. This past noncompliance occurred from July 23, 2026 to July 24, 2026. The findings include:R1's face sheet printed on 8/28/26 showed R1 has diagnoses including but not limited to displaced intertrochanteric fracture of left femur, generalized anxiety disorder, depression, unsteadiness on feet, lack of coordination, and dementia without behaviors.R1's facility assessment dated [DATE] showed R1 has… […]

• Actual harm, isolatedF689Nov 14, 2025

  Based 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. The findings include: R1's Face Sheet, dated 11/13/25, showed diagnoses including metabolic encephalopathy, gastrointestinal hemorrhage, asthma, atrial fibrillation, pneumonia, bacteremia, bullous pemphigoid, gastroesophageal reflux disease, hypertension, and tinea unguium.R1's Minimum Data Set (MDS), dated [DATE], showed no cognitive impairment; chair/bed transfer - dependent; toilet transfer - dependent.R1's Care plan, dated 10/19/25, showed R1 has… […]

• Actual harm, isolatedF689Jun 20, 2024

  Based 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. The findings include: R1's admission record documents she was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's disease and cognitive communication deficit. The 5/23/24 quarterly assessment of R1 shows she has severe cognitive impairment and is dependant on staff for chair/bed to chair transfers. The 6/19/24 300 hall resident information lists R1 as a transfer with a mechanical lift with 2 assist. On 6/20/24 at 9:50 AM, R1 was observed sitting up in her chair. She was alert, but non verbal. She had a mechanical lift sling underneath her. […]

• Actual harm, isolatedF692Sep 1, 2023

  Based 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. The findings include: 1. R59's face sheet printed on 8/30/23 showed diagnoses including right sided hemiplegia (paralysis), expressive language disorder, metabolic encephalopathy, anxiety, dysphagia (difficulty swallowing), and unsteadiness on feet. R59's facility assessment dated [DATE] showed severe cognitive impairment and extensive to total staff assistance needed for bed mobility, transfers, locomotion, dressing, eating, toilet use, and hygiene. […]