Pleasant View Luther Home

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on interview and record review, the facility failed to implement safety interventions for a resident at moderate risk for falls while on the toilet for one (Resident R2) of three residents reviewed for falls in a sample of three. The facility's Mechanical Lift policy, reviewed 5/23/25, documents for the Power Stand-Up Lift Procedure: Assemble all supplies within reach, including lift and lift harness. b. Position the top of the harness around the upper body of the resident (approximately 4-5 inches below the underarm). c. Securely fasten the harness safety strap around the resident's chest. This form documents that when lifting a resident from a wheelchair or other chair, secure the harness loops onto the lift. b. Secure the shin straps around the resident's legs. The facility's Falls Prevention and Post-Falls Management policy, reviewed 9/6/25, documents that the staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait balance, excessive motor activity, activities of daily living capabilities, activity tolerance, continence, and cognition. Resident R2's Fall Risk Assessment, dated 10/13/25, documents that Resident R2 is at moderate risk for falls. Resident R2's Incident Description, dated 10/11/25, documents that Resident R2 had been transferred via sit-to-stand mechanical lift to the toilet. V8, Certified Nursing Assistant, removed the lift sling and raised the enabler bar to perform personal hygiene. Resident R2 was unable to maintain posture and balance on the toilet and fell to the floor. This form documents V4, Resident R2's Spouse, requested to take Resident R2 to the emergency room. The root cause analysis determined that Resident R2 had impaired mobility and poor sitting/standing balance. Resident R2 was unable to maintain posture or balance on toilet during personal hygiene care. Resident R2 leaned to one side and fell off the toilet to the floor. Team member (V8) had placed the enabler bar in upward position to provide more room during personal hygiene cares and was unable to prevent fall. Team member education provided regarding use of enable bars and safety awareness when providing cares for resident with impaired sitting/standing balance.

On 11/15/25 at 10:45 a.m., V6, Certified Nursing Assistant, stated that the enabler bars in the bathrooms are used by residents who are able to stand independently but may need some assistance with standing and balancing. On 11/15/25 at 11:45am, V8 stated that he assisted Resident R2 to the toilet with the sit-to-stand lift.

V8 stated that he unhooked Resident R2 from the mechanical lift to clean him up V8 stated that he raised the enabler bar to provide incontinence care V8 stated that he put Resident R2's pull-up and pants back on, then lifted his feet to put them on the sit-to-stand, and Resident R2 fell off the toilet. V8 verified that he put Resident R2's feet onto the sit-to-stand first instead of applying the top harness. V8 stated that he should have applied the top harness, then attached it to the lift before lifting his feet on the foot pedal. V8 verified that Resident R2 was unable to balance or stand without assistance.

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

Event ID:

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

11/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pleasant View Luther Home

505 College Avenue Ottawa, IL 61350

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 0745

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review, the facility failed to implement psychosocial service interventions for one of three residents (Resident R1) reviewed for social services in sample of three. Findings include:The facility's Behavioral Health policy, reviewed 12/18/24, documents that the organization will provide residents with behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. This form documents that behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care, and residents who exhibit signs of emotional/psychosocial distress receive services and supportthat address their individual needs and goals for care. On 11/15/25 at 8:45am, Resident R1 stated that he and his wife lived in an apartment in the assisted living portion of the facility. Resident R1 stated that he and his wife had separated and are getting divorced after 40-plus years of marriage. Resident R1 stated that he was moved to the long-term part of the facility because of the divorce and he can not be around his wife. Resident R1 stated that he feels very depressed and will act out at times, because he does not know how to handle the personal situation he is going through. Resident R1 stated that the only time V9, Social Service Director or any other staff, speaks to him is when he is in trouble. Resident R1 stated that she, nor anyone else, ever asked him what he might be feeling or going through. On 11/15/24 at 12:40pm, V9 verified that Resident R1 is not in any psychosocial programming. V9 stated that she has not assessed or asked him about his feelings concerning his divorce. V9 also verified that she does not have any psychosocial programs within the facility. V9 stated that the residents go to activities.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet