Prairieview Lutheran Home

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

she does not like the sit to stand lift, but there were no transfer issues during V12's shift. On 10/28/25 at 2:42 PM, V15 LPN stated V15 was alerted to a bruise on (Resident R1's) right chest and arm by the CNAs on 9/21/25. V15 stated V15 felt the bruise lined up with the belt on the stand lift that Resident R1 used to transfer. V15 denied any knowledge of any incidents that could have caused Resident R1's bruising. On 10/28/25 between 4:01 PM and 4:43 PM, V27 and V28 CNAs stated they found Resident R1's bruising on the evening of 9/21/25 prior to transferring her to bed, which was not noted when V28 had last cared for Resident R1 the night before. V27 stated something must have happened during the dayshift. V28 described the bruise as purple, almost black, extending from the base of Resident R1's neck down to the bottom of Resident R1's abdomen, across from mid chest to right under arm before the elbow. V27 stated initially Resident R1 was a stand pivot transfer but then Resident R1 started using the sit to stand lift a few weeks prior. V27 stated Resident R1 disliked the stand lift, Resident R1 would tell us that she was hurting and didn't like the lift, and to put Resident R1 down. V27 stated Resident R1 couldn't stand in the lift for very long, so staff had to move Resident R1 quickly. V27 and V28 were not aware of the cause of Resident R1's injury, or any falls or incidents that could have caused Resident R1's injury. On 10/29/25 at 8:55 AM, V21 Memory Care Director stated V21 did not work

on 9/21/25 and received a text message that evening from V15 Licensed practical Nurse reporting Resident R1's bruising. V21 stated no one saw anything happen and staff were unsure what caused the bruising. V21 stated V15 LPN told V21 that the bruise aligned with the stand lift sling, so V21 assumed that was the cause of Resident R1's injury. On 10/29/25 at 1:27 PM, V1 Administrator stated V1 assisted collectively with nurse management for the investigation of Resident R1's 9/21/25 bruising/injury. V1 stated V15 LPN, and the two CNAs were interviewed for this investigation. V1 confirmed no other staff were interviewed. V1 stated the interviewed staff were asked about what happened and how Resident R1 had been that day/evening. V1 stated the staff only talked about Resident R1 in the sling and how she played balloon toss with a pool noodle that afternoon.

V1 was asked to clarify what the staff mentioned about the stand lift sling and V1 stated meaning Resident R1 transferred with the stand lift and sling that day. V1 said there were no reported accidents, injuries, or concerns related to the sling use. V1 confirmed staff were not asked if Resident R1 had any falls/incidents or what caused Resident R1's injury. V1 stated the staff report resident falls. V1 stated V1 reviewed video surveillance footage of Resident R1 on the afternoon of 9/21/25 participating in an activity that involved using a pool noodle to strike a balloon.V1 stated based on this observation, V1 questions if Resident R1's stretching and repetitive arm movements during the activity may have contributed to a vascular injury, such as a tear in an artery, which could potentially explain the bruising observed on Resident R1. V1 confirmed no other video surveillance was reviewed. The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 12/23/21 documents the investigation process is used to try to determine the cause of injuries of unknown source and rule out abuse. This policy documents the designated investigator will begin the investigation immediately to implement a root cause investigation and analysis, and the gathered information is given to the administrator. The investigation may include who was involved, resident statements, roommate statements, involved staff and witness statements, a description of the resident's behavior and environment at the time of the incident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Prairieview Lutheran Home

403 North Fourth Street Danforth, IL 60930

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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

description of the bruising and/or change of condition. This policy revision will be completed, and nurses will be in-serviced on the policy by the end of the day on [DATE REDACTED]. Verified [DATE REDACTED].g. The TAR was updated on [DATE REDACTED] for all residents who are currently on an anti- coagulant medication: Observe for adverse reactions of ANTICOAGULANT therapy every shift: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath (SOB), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs (v/s). Verified in place [DATE REDACTED]. 2. The following systematic changes have been implemented.a. The Lift Assessment will be completed for all residents who need a mechanical lift upon admission, quarterly, or as needed if their transfer status is changed. This will be completed by the Restorative Nurse and Therapy Staff by the end of the day on [DATE REDACTED]. Verified [DATE REDACTED].b. Following the change in a lift status, DON / ADON / Restorative Nurse or Designee will monitor and reassess three times a week for two weeks. Initiated [DATE REDACTED]. Ongoing.c. If a resident shows signs of bruising and is on an anti-coagulant, the MD will immediately be notified and then the nurse on duty will monitor and reassess the bruise hourly times hours, then every four hours for the remaining initial 24 hours, then every shift for six days. If bruising increases and/or there are signs of a change in condition, the MD will immediately be notified. Initiated [DATE REDACTED].d. All above education will be provided by the Education Nurse initially beginning on [DATE REDACTED], for all new hires, and then monthly for three months. Initiated [DATE REDACTED]e.

Random audits on mechanical lift transfers will be conducted by the Nurse Leadership weekly for 12 weeks. [DATE REDACTED] the form was provided. Confirmed with V2 she will be completing the audits.f. Random audits on nursing documentation regarding residents who are on anti- coagulant medications will be completed by nursing leaders weekly x 12 weeks, to ensure proper orders are in place and appropriate follow-up for signs/symptoms of adverse reactions are documented. [DATE REDACTED] form provided. Confirmed with V2 she will be completing the audits.3. The following Quality Assurance Programs have been implemented:a. Lift Assessments and Transfer Status' will be added to the IDT weekly QA reporting for review. This will be presented by the Restorative Nurse and/or Therapy. Verified [DATE REDACTED].b. Any injuries noted in relation to a transfer with a mechanical device will be reviewed in the daily QA meeting with the IDT. This will be presented by the IDT Nurse Leaders. Verified [DATE REDACTED]. Confirmed with V2 she will be responsible for this.c.

Residents on anti-coagulants and with new bruising will be added to the IDT daily QA reporting for review by the IDT Nursing Leaders. Verified [DATE REDACTED]. Confirmed with V2 she will be responsible for this.d. Any incidents regarding the monitoring of residents on anti-coagulant medications will be reviewed at the daily QA meeting with the IDT and presented by the IDT Nurse Leadership. [DATE REDACTED] Confirmed with V2 she will be responsible for this.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Prairieview Lutheran Home

403 North Fourth Street Danforth, IL 60930

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 - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

interview and record review the facility failed to safely transfer a resident (Resident R7) resulting in a fall and failed to investigate this fall for one of four residents (Resident R7) reviewed for accidents in the sample list of 10. On 10/27/25 at 10:14 AM, Resident R7 stated Resident R7 had a recent fall while trying to get into bed with staff assistance. Resident R7 stated a gait belt was not used during this transfer. Resident R7's Minimum Data Set, dated [DATE REDACTED] documents Resident R7 as cognitively intact, Resident R7 requires partial/moderate staff assistance for chair/bed transfers, and Resident R7 had two or more falls without injury since the prior assessment. Resident R7's Care Plan dated 8/26/24 documents Resident R7 is at risk for falls, Resident R7 has a transfer restorative program due to weakness and Resident R7 transfers with one assist, gait belt, and grab bar or walker. Resident R7's Endurance-Functional Mobility assessment dated [DATE REDACTED] documents Resident R7 transfers with one assist with use of gait belt, grab bar or walker. Resident R7's Nursing Note dated 9/4/2025 at 8:22 PM documents Resident R7 was being assisted into bed from his wheelchair, Resident R7 let go of the bed rail, Resident R7's knees weakened and Resident R7 was assisted to the floor. Resident R7 did not sustain any injuries. The post fall intervention was to use two assist for transfers in/out of bed. The Accident Investigation/Interview Form dated 9/4/25 documents V19 Certified Nursing Assistant (CNA) assisted Resident R7 with transfer from wheelchair to bed, Resident R7 let go of the railing, Resident R7's knees became weak, and Resident R7 was lowered to the floor. This form does not document whether a gait belt was used. There is no documentation that this fall was thoroughly investigated. On 10/27/25 at 1:18 PM, V2 Director of Nursing stated the nurse documented Resident R7's fall in the 9/4/25 nursing note but didn't complete an incident report. V2 confirmed there was no fall investigation packet completed for this fall. On 10/27/25 at 3:09 PM, V19 CNA confirmed V19 assisted Resident R7 during the fall on 9/4/25. In reference to this fall, V19 stated V19 transferred Resident R7 from the bathroom into the wheelchair and V19 was in

the process of transferring Resident R7 into bed. V19 stated Resident R7 went to grab the siderail on his bed, Resident R7 let go with one of his hands to grab his pants while standing, Resident R7 lost his balance and fell. V19 stated at that time Resident R7 was a one assist for transfers. V19 stated V19 did not use a gait belt during this transfer. On 10/28/25 at 3:58 PM, V18 Licensed Practical Nurse confirmed V18 completed Resident R7's Endurance-Functional Mobility assessment dated [DATE REDACTED] and confirmed Resident R7's transfer status at that time was one assist and gait belt. V18 stated staff would also have Resident R7 use the grab bars in his bathroom, on recliner, and on bed, and/or wheeled walker. The facility's undated Managing Falls and Fall Risk policy documents: 1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g. (for example), dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Prairieview Lutheran Home

403 North Fourth Street Danforth, IL 60930

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 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Based on interview and record review the facility failed to have the physician document and sign progress notes for each visit for five of six residents (Resident R1, Resident R2, Resident R5, Resident R9, Resident R10) reviewed for physician visits in the sample list of 10. 1.) Resident R1's undated Face Sheet documents Resident R1's primary physician as V25. Resident R1's Progress Notes, recorded by V10 Licensed Practical Nurse, document V25 evaluated Resident R1 on 6/27/25, 8/22/25 and 9/9/25. As of 11/3/25, Resident R1's electronic medical record (EMR) did not include any Physician Progress Notes by V25. 2.) Resident R2's undated Face Sheet documents Resident R2's primary physician as V25. Resident R2's Progress Notes, recorded by V10, document V25 evaluated Resident R2 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, Resident R2's EMR did not include any Physician Progress Notes by V25. 3.) Resident R5's undated Face Sheet documents Resident R5's primary physician as V25. Resident R5's Progress Notes, recorded by V10, document V25 evaluated Resident R5 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, Resident R5's EMR did not include any Physician Progress Notes by V25. 4.) Resident R9's undated Face Sheet documents Resident R9's primary physician as V25. Resident R9's Progress Notes, recorded by V10, document V25 evaluated Resident R9 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, Resident R9's EMR did not include any Physician Progress Notes by V25. 5.) Resident R10's undated Face Sheet documents Resident R10's primary physician as V25. Resident R10's Progress Notes, recorded by V10, document V25 evaluated Resident R10 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, Resident R10's EMR did not include any Physician Progress Notes by V25. On 11/4/25 at 8:10 AM, V2 Director of Nursing stated the physician visit notes are documented under the assessments or uploaded into the resident's EMR in the miscellaneous section. V2 stated sometimes they have to request for the physician to send them to the facility. At this time V25's Progress Notes were requested for Resident R1, Resident R2, Resident R5, Resident R9 and Resident R10. At 9:55 AM, V2 stated V2 had to request V25's Progress Notes. On 11/4/25 at 1:49 PM, V25 stated V25 sees each resident at least every 60 days, tries to open a progress note at the time of each visit and tries to have an office day to complete the visit notes, but that doesn't always happen.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/05/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Prairieview Lutheran Home

403 North Fourth Street Danforth, IL 60930

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 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Based on interview and record review the facility failed to ensure all staff were trained on the facility's Quality Assurance Performance Improvement Program. This failure affects all 84 residents in the facility.

The facility's Facility assessment dated as reviewed 9/26/25 includes staff education/training upon hire and annually through (web-based training and education system), new employee orientation, and in-services.

This Facility Assessment does not include QAPI training as one of the topics that staff will be trained on. On 11/4/25 at 10:55 AM, employee education and training were reviewed with V48 Human Resources and V48 was asked about QAPI training. V48 confirmed there was no documentation of QAPI training in the (web-based training and education system) or as part of the facility's new employee orientation training.

V48 stated V48 will have to follow up with V33 Nurse Educator to see if there is any training on QAPI. At 12:35 PM, V48 stated QAPI training has not been completed since 2020. On 11/4/25 at 1:16 PM, V33 Nurse Educator confirmed QAPI training has not been completed. V33 stated V33 just added QAPI training

in (web-based training and education system) for all staff and the staff have a week to complete it. The facility's Resident Roster dated 10/27/25 documents a census of 84 residents.

Event ID:

Facility ID:

If continuation sheet