Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure a resident was transferred and
ambulated in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. These failures
resulted in R1 sustaining a fractured nasal bone, sutures to the forehead, and bruising.
The findings include:
R1's face sheet printed on 12/6/23 showed diagnoses including but not limited to Alzheimer's disease,
dementia with agitation, anxiety disorder, wandering, impulsiveness, difficulty walking, muscle weakness,
and abnormalities of gait and mobility. R1's facility assessment dated [DATE] showed severe cognitive
impairment. The assessment showed substantial/maximal staff assistance needed for transferring from
sitting to standing. The assessment showed partial/moderate staff assistance required for walking once
standing.
R1's fall risk assessment dated [DATE] showed a high risk for falls.
R1's progress note dated 12/2/23 at 6:02 AM stated: Called to resident room for witnessed fall. Resident
found on floor with laceration to forehead above right eyebrow. Assessed resident and call 911 for ER
transport. Resident made comfortable with C spine supported until EMS arrived. Pressure applied to
laceration with woven sponge . The note documented R1 was found on the floor at 4:39 AM and was sent
to the local emergency room at 5:00 AM. The note was written by V4 (Registered Nurse).
R1's progress note dated 12/2/23 at 6:20 AM stated: ED (emergency department) called with report,
resident has fractured nasal bone, 3 stitches to laceration over right eyebrow-per report and will be
returning to facility. MD notified, DON and administrator informed of fall, ED visit and pending return to the
facility.
On 12/6/23 at 9:00 AM, R1 was lying in bed dressed and covered with a light blanket. R1 had dark, purple
crescent shaped bruises under both eyes and a 2x2 inch dressing on her forehead over the right eyebrow.
R1's right arm was uncovered, and a quarter size dark purple bruise was on top of her right hand with
scattered smaller bruises on her arm. R1 was awake but did not respond or react to any questions. R1's
room was located on the dementia unit of the facility.
On 12/6/23 at 11:15 AM, V8 (CNA-Certified Nurse Aide) assisted R1 out of bed and across the room to the
bathroom. R1 was nonverbal and walked in a shuffling, unsteady manner. V8 used a gait belt to steady R1
and a walker during the transfer and while walking. At 2:10 PM, V8 stated the following: R1 needs help
while getting out of bed and walking. R1 walks unsteady and cannot follow directions. R1
(continued on next page)
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
Page 1 of 3
Event ID:
145414
Printed: 05/15/2026
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
145414
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Crossing Lvg & Rehab
409 West Comanche Road
Shabbona, IL 60550
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 - Actual harm
Residents Affected - Few
is confused and will walk away during care. R1 tries to walk while her pants are still at her ankles. R1 will
just give up and plop herself down into the bed. R1 needs a walker and gait belt for safety. It provides R1
something to hold onto and she doesn't walk safely without both.
On 12/6/23 at 10:40 AM, V3 (CNA) stated she was working the night shift on 12/2/23 and took R1 to the
toilet at around 4:30 AM. V3 said she sat R1 at the side of the bed and directed R1 to grasp her around the
waist, like a bear hug. V3 said she stood R1 up by holding her hands and placed the wheeled walker in
front of R1. V3 said she walked R1 to the bathroom and changed her into day clothes while toileting R1. V3
said she had to close the bathroom door during care to prevent R1 from walking away from her. V3 said she
directed R1 back across the room and to the bed side. V3 said she stood in front of the walker and pulled
on it to guide R1 toward the bed. V3 stated she turned away from R1 to adjust the bed linens and R1
walked away from her, toward the closet door. V3 said R1 was walking by herself and out of grasp. R1
suddenly fell forward and pushed the walker to the side during the fall. V3 said R1 did not reach out with her
hands and fell face first to the floor. V3 said she hit the floor full impact. V3 said R1 began bleeding and she
immediately yelled for V4 (Registered Nurse). V3 was questioned if R1 was wearing a gait belt and if V3
holding onto it. V3 said, no. The thought never crossed V3's mind and V3 didn't have a gait belt with her at
the time. V3 said R1 needs a gait belt and walker to be moved safely. V3 said she has cared for R1 in the
past and was familiar with her mental confusion and unsteady walking.
On 12/6/23 at 1:26 PM, V4 (Registered Nurse) stated she was working the night shift on 12/2/23 and heard
V3 (CNA) yelling out for help around 4:40 AM. V4 said she went to R1's room and found R1 on the floor
bleeding from the nose. V4 said she immediately called the physician and orders were received to send R1
to the emergency room. V4 said R1 was dressed in day clothes and her walker was near her. R1 was
wearing anti-skid socks but not a gait belt. V4 said R1 is confused and has a weak gait. R1 needs staff help
to stabilize her during transfers and walking to prevent her from falling. V4 said R1 returned to the facility
the same morning and was diagnosed with a fractured nasal bone. R1 required stitches to her forehead
and had bruising to her right arm and face.
On 12/6/23 at 12:50 PM, V5 (Registered Nurse) stated R1's ambulation skills have been decreasing due to
her disease progression. R1 is confused and will walk by herself if staff do not guide her. V5 said R1 needs
more and more help to walk safely. V5 said R1 is becoming weaker and more unsteady and needs a
wheelchair on her extremely weak days. V5 said R1 should always have a gait belt and walker with her to
maintain balance. It is an extra way for CNAs to hold and stabilize R1.
On 12/6/23 at 2:38 PM, V9 (Physical Therapist) stated he has worked with R1 in the past and was familiar
with her needs. V9 said R1 needs a lot of help transferring and walking safely. Staff should be using a gait
belt and standing at her side to guide her. Pulling the front of a walker to direct a resident is not appropriate.
V9 said gait belts are required for any resident who is a high fall risk.
On 12/6/23 at 11:35 AM, V2 (Director of Nurses/Fall Coordinator) stated prior to R1's 12/2/23 fall she was
under standard fall interventions. V2 said R1 did not have gait belt use cared planned but they are required
for any resident who is unsteady. V2 said, gait belts are used to have something to hold onto and staff can
gently lower a resident to the floor if need be. At 12:11 PM, V2 was asked for the facility policy related to
gait belt use. At 2:43 PM, V2 was asked for the facility policies related to resident transfers and resident
ambulation. V2 stated the facility did not have any policies regarding the topics requested.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145414
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
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
145414
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/06/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Crossing Lvg & Rehab
409 West Comanche Road
Shabbona, IL 60550
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
R1's emergency room after visit summary dated 12/2/23 showed the reason for the visit was fall related.
R1's resulting diagnoses showed a cut on forehead and a nose fracture.
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility's Fall Prevention and Management policy last review dated 9/29/23 states under the fall
prevention section: 7. All staff must observe residents for safety. If residents with a high-risk code are
observed up or getting up, help must be summoned or assistance must be provided to the resident. Staff
will be educated on the fall reduction and prevention program.
Event ID:
Facility ID:
145414
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the December 6, 2023 survey of PRAIRIE CROSSING LVG & REHAB?
This was a inspection survey of PRAIRIE CROSSING LVG & REHAB on December 6, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PRAIRIE CROSSING LVG & REHAB on December 6, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.