Health 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. Page 1 of 2 145927 145927 04/28/2025 Prairie Oasis 16000 South Wabash South Holland, IL 60473

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some R8's care plan documents in part, R8 at risk for falls R/T Requires ADL (activities of daily living) assist for transfers and mobility related tasks. Staff to monitor R8 for safety. Date initiated: 03/23/2025. R9's care plan documents in part, R9 is at risk for falls related to decreased safety awareness, impaired range of motion and/or loss of functional movement of joint(s), decreased strength and endurance. R9 will have a safe environment maintained thru the next review. Staff to monitor R9 while in room and anticipate her needs. Date initiated: 03/10/2025. R10's care plan documents in part, R10 is at risk for falls r/t antidepressant medication and unsteady gait and history of fall, requiring assistance with ADL's and transfers. Staff to continue to monitor R10 for safety. Date initiated: 03/23/2025. R11's care plan documents in part, R11 is at risk for falls related to requires ADL assist for transfers and mobility related tasks. R11 will have a safe environment maintained thru the next review. Monitor resident when in the room date initiated: 06/22/2024. R12 at risk for falls related to decreased safety awareness. R12 will have a safe environment maintained thru the next review. Staff to monitor for R12's safety. Date initiated: 03/17/2025. Record review of the CNA assignment sheet for unit 100 dated 04/26/2025, documents that dining room monitoring times begin at 9:00 AM. No staff member is scheduled or responsible for monitoring the dining room until 9:00 AM. Record review of the CNA assignment sheet for unit 300 dated 04/26/2025, documents that V11 is responsible for monitoring the 300-unit dining room from 1:00 PM-2:00 PM. Facility policy dated 03/2015, titled, Supervision and Safety documents in part, Policy: Our policy strives to make the environment as free from hazards as possible. Resident safety and supervision are facility-wide priorities. 4. Resident supervision is a core component to resident safety. 9. Staff to decrease safety risk factors as much as possible. 145927 Page 2 of 2