Inspection·April 28, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for residents. This failure affects six (R7, R8, R9, R10, R11, R12) out of twelve residents reviewed for supervision and monitoring. Findings include: On 04/26/2025, at 8:41 AM, R7 observed sitting in a wheelchair inside of the first-floor 100-unit dining room unsupervised and unattended. On 04/26/2025, at 8:57 AM, V7 (CNA) walked inside of the 100-unit dining room and stated she is responsible for caring for R7 today. V7 stated R7 should be monitored and supervised while sitting in the dining room but V7 can't watch everybody. V7 stated if residents are left unsupervised and no one is monitoring the residents, then residents could potentially fall or choke while eating. On 04/26/2025, at 1:17 PM, R8, R9, R10, R11, and R12 observed sitting inside of the first floor 300-unit dining room unsupervised and unattended. R8, R9, and R11 were sitting in wheelchairs. On 04/26/2025, at 1:18 PM, V2 (Director of Nursing/DON) walked inside the 300-unit dining room and walked back out. On 04/26/2025, at 1:19 PM, V11 (Certified Nursing Assistant/CNA) was observed walking inside of the 300-unit dining room. V11 stated she is aware that she was supposed to be monitoring the residents because it is her designated monitoring time written on the schedule. V11 stated if residents are not properly monitored, then they can potentially fall or injure themselves. On 04/26/2025, at 1:19 PM, shortly after V11 arrived in the 300-unit dining room. V13 (CNA) also arrived in the 300-unit dining room. V13 stated she was informed by V2 that no one was inside of the 300-unit dining room monitoring the residents. On 04/26/2025, at 1:25 PM, V13 stated there is supposed to be someone inside of the dining room monitoring the residents at all times. V13 stated the purpose of monitoring residents is to ensure they do not fall. R7's care plan documents in part, R7 is at risk for fall due to an unsteady gait and I have a diagnosis of dementia and may be unaware of safety limits. I use a wheelchair for mode of locomotion. Make sure R7 is sitting back in the wheelchair. Monitor more frequently: keep in the staff's sightline while awake. Staff to continue to monitor R7 for safety. Date initiated: 03/17/2025. (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 2 Event ID: 145927 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 145927 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Oasis 16000 South Wabash South Holland, IL 60473 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)