Inspection·October 3, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure daily weights were obtained for a resident with a diagnosis of heart failure, and failed to notify the resident's doctor when weight gain was outside of the set parameters for 1 of 1 resident (R19) reviewed for congestive heart failure (CHF) in the sample of 15. Residents Affected - Few The findings include: R1's admission Record, printed by the facility on 10/2/24 showed he had diagnoses including, but not limited to, heart failure, dementia, Parkinson's disease, anxiety, depression, and obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). R19's Order Summary Report, printed by the facility on 10/2/24, showed an order dated 5/14/24 for daily weights and to update V13 (R19's Cardiologist) if R19 had a gain of more than 2-3 pounds (lbs.) overnight or 5 pounds (lbs.) in a week. The report showed the order was still active on 10/2/24. R19's facility assessment dated [DATE] showed he had severe cognitive impairment, required partial/moderate assistance from staff for toileting, bathing, and transfers, and substantial to maximal assist for lower body dressing and putting on/taking off footwear. Section I of the assessment showed R19's primary medical condition was debility, cardiorespiratory conditions. R19's undated/untitled document, provided by the facility on 10/3/24 showed R19's weight on 6/30/24 was 201.6 lbs. R19's Weights and Vitals Summary, printed by the facility on 10/2/24, showed R19's weight on 7/1/24 was 204.9 lbs. (a 3.3 lb. gain in one day). R19's Weights and Vitals Summary, printed by the facility on 10/2/24, also showed the following: On 7/5/24 R19 weighed 200.6 lbs. On 7/6/24 R19 weighed 206.5 lbs. (a 5.9 lb. increase). On 7/24/24 R19 weighed 201.4 lbs. On 7/25/24 R19 weighed 208.3 lbs. (a 6.9 lb. increase). On 8/6/24 R19 weighed 199.9 lbs. No weight was entered for 8/7/24. On 8/8/24 R19 weighed 206.1 lb. (a 6.2 lb. increase). On 9/26/24 R19 weighed 198.5 lbs. On 9/27/24 R19 weighed 202.9 lbs. (an increase of 4.4 lbs.). On 9/29/24 R19 weighed 203.3 lbs. On 9/30/24 R19 weighed 206.6 lbs. (an increase of 3.3 lbs.). (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 10/03/2024 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)