Inspection·November 15, 2025

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 (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. R2's Fall Risk Assessment, dated 10/13/25, documents that R2 is at moderate risk for falls. R2's Incident Description, dated 10/11/25, documents that 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. R2 was unable to maintain posture and balance on the toilet and fell to the floor. This form documents V4, R2's Spouse, requested to take R2 to the emergency room. The root cause analysis determined that R2 had impaired mobility and poor sitting/standing balance. R2 was unable to maintain posture or balance on toilet during personal hygiene care. 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 R2 to the toilet with the sit-to-stand lift. V8 stated that he unhooked 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 R2's pull-up and pants back on, then lifted his feet to put them on the sit-to-stand, and R2 fell off the toilet. V8 verified that he put 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 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 Page 1 of 2 Event ID: 145801 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 145801 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)