Inspection visit
Inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure that dignity was maintained, by failing
to respond to a call light in a timely manner. This failure resulted in a delay in meeting toileting needs for a
dependent resident and prevented a residents right to participate in a scheduled activity. This failure
affected one of 21 residents (R11) reviewed for dignity on the sample list of 21.
Findings include:
R11's Physician Order Summary Report dated 9/27/23 documents the following diagnoses: Multiple
Sclerosis, Muscle Weakness, Spondylosis (Osteoarthritis of the spine), and General Anxiety Disorder.
R11's Minimum Data Set (MDS) dated [DATE] documents the following: R11's Brief Interview of Mental
Status score of 14 out of a possible 15, indicating R11 has no cognitive impairment. The same MDS
documents R11 requires extensive assistance of two people for toileting and is totally dependent on two
person for transfers.
R11's Care Plan updated 8/23/23 documents the following: Self Care deficient. Needs supervision and/or
assistance to provide quality of care, and/or poorly motivated to completed Activities of Daily Living (ADL's)
related to weakness. As evidence by requires supervision to total staff dependence to complete ADL's.
The same Care Plan documents the following: Strength: (R11) attends many activity programs. As
evidenced by regularly attending Bingo and crafts.
On 9/27/23 a 2:12 pm, R11's call light was activated by sound and light outside R11's room on the 100 hall.
V2, Director of Nursing (DON) and four additional unidentified staff were just outside R11's room in the hall.
The five staff were adjusting a low bed that had been moved from an adjacent room. Four additional
unidentified staff (total of nine) passed by R11's room as the call light remained activated. The call light
above R11's door was on, the call light illuminated and sound was activated at the nurses station and
above V2's DON door at the end of the 400 hall. The 400 hall displayed a call light on and had a sign with
R11's room number on 100 hall displayed to indicate R11's call light was on.
On 9/27/23 continuous observation continued until 2:42 pm (total observed 30 minutes). R11 could be
heard from the hall moaning. There was no staff response. R11 stated Please get the girls (CNA's) to take
me off this bed pan. It hurts. I have been on it (bedpan) for over an hour. R11 stated It takes two people to
help me. I have MS (Multiple Sclerosis).
(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 7
Event ID:
145953
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
145953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairieview Lutheran Home
403 North Fourth Street
Danforth, IL 60930
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 9/27/23 at 2:45 pm V2, Director of Nursing acknowledged there should never be a wait time for a
resident on a bed pan. (R11's) call light should have been answered right away. V2, DON also stated I will
make sure R11 gets the assistance she needs right away.
On 9/27/23 at 2:50 pm, R11 was laying in bed, on a bedpan. V9 and V10 Certified Nursing Assistants
(CNA) entered R11's room. R11 stated, My call light was on for well over an hour. At 1:40 pm (one hour and
two minutes total call light activation), (V7, CNA) and (V8, CNA) were suppose to come back and get me
out of bed for bingo at 2:00 pm. That didn't happen. My call light was on the whole time, until now.
On 9/27/23 at 4:35 pm V1, Administrator stated he emphasizes to all staff to answer call lights. V1 stated he
answers call lights as well. V1 stated, I saw (R11s) light out of the corner of my eye. I was focused on
something else. I helped with the move of another resident bed just outside (R11's) room. There should
have never been eight or nine staff in the hall that walked by her light, including myself.
The facility policy Dignity revised February 2021 documents the following:
Policy Statement,
Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being,
level of satisfaction with life, and feelings of self-worth and self-esteem.
Policy Interpretation and Implementation
1. Residents are treated with dignity and respect at all times.
2. The facility culture supports dignity and respect for residents by honoring resident goals, choices,
preferences, values and beliefs. This begins with the initial admission and continues throughout the resident
' s facility stay.
3. Individual needs and preferences of the resident are identified through the assessment process.
4. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any
person or entity associated with this facility.
5. When assisting with care, residents are supported in exercising their rights. For example, residents are:
a. groomed as they wish to be groomed (hair styles, nails, facial hair, etc.);
b. encouraged to attend the activities of their choice, including religious, political, civic, recreational, or
social activities;
The same policy documents the following:
12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected
to promote dignity and assist residents; for example:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145953
If continuation sheet
Page 2 of 7
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
145953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairieview Lutheran Home
403 North Fourth Street
Danforth, IL 60930
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 0550
a.
Level of Harm - Minimal harm
or potential for actual harm
helping the resident to keep urinary catheter bags covered;
b.
Residents Affected - Few
promptly responding to a resident ' s request for toileting assistance; and
c.
allowing residents unrestricted access to common areas open to the public, unless this poses a safety risk
for the resident.
The facility policy Call System, Residents dated September 2022 documents the following:
Residents are provided with a means to call staff for assistance through a communication system that
directly calls a staff member or a centralized work station.
Policy Interpretation and Implementation Number 6. Calls for assistance are answered as soon as possible.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145953
If continuation sheet
Page 3 of 7
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
145953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairieview Lutheran Home
403 North Fourth Street
Danforth, IL 60930
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to use proper sequence anterior then posterior
technique, perform hand hygiene, remove soiled gloves, and prevent cross contamination during perineal
care for a resident with a Urinary Tract Infection (UTI). This failure affected one of four residents ( R11)
reviewed for a UTI on the sample list of 21.
Findings include:
R11's Physician Order Summary Report Sheet (POS) dated 9/27/23 documents the following: Levaquin
(antibiotic) Oral Tablet 500 milligrams (mg) (Levofloxacin), Give 500 mg by mouth in morning for UTI
(Urinary Tract Infection) for 5 days.
R11's Minimum Data Set (MDS) dated [DATE] documents R11's Brief Interview of Mental Status score of
14 out of a possible 15, indicating R11 has no cognitive impairment. The same MDS documents R11
requires extensive assistance of two people for toileting and is totally dependent on two person for transfers
R11's Care Plan updated 9/25/23 problem: (R11) is on antibiotic therapy, Levaquin related to Urinary Tract
Infection.
R11's laboratory Urine Culture dated as collected 9/20/23 documents the following bacterial infection:
Enterococcus faecalis greater than one-hundred-thousand colony forming units per milliliter.
On 9/27/23 at 2:50 pm R11 was laying in bed, on a bedpan. V9 and V10 Certified Nursing Assistants (CNA)
entered R11's room. V9, CNA washed her hands and donned gloves. V10, donned gloves without
performing handwashing or using hand sanitizer. V9, and V10, CNA positioned R11 to a left side-lying
position. V10, CNA removed the bedpan from under R11's buttocks. V9, CNA assisted R11 to maintain
R11's left-side lying position.
V10, CNA knocked R11's package of disposable wipes off R11's bedside dresser, onto the floor. V10, CNA
picked up the contaminated disposable wipe package, opened the package, and removed the wipes with
the contaminated gloves. V10 proceeded with the same contaminated gloves, and performed posterior
perineal care. V10 did not complete anterior perineal care first as the facility policy directs. V9 and V10
re-positioned R11 to a back lying position. With the same soiled gloves, V10 reached for the disposable
wipes on the edge of the bedside dresser. V10 again dropped the disposable wipes package on the floor.
V10 picks up the disposable wipes package and removed disposable wipes from the package with the
same contaminated gloves. V10 proceeds to perform anterior perineal care with the contaminated
disposable wipes and without removing the same soiled gloves used for R11's posterior perineal care.
On 9/27/23 at 3:25 pm V2, Director of Nursing stated V2's expectation is staff wash their hands and don
clean gloves during peri-care to prevent cross contamination.
On 9/27/23 at 3:35 pm V10, CNA acknowledged cross-contamination during perineal care, failure to
provide R11 anterior perineal care before posterior perineal care.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145953
If continuation sheet
Page 4 of 7
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
145953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairieview Lutheran Home
403 North Fourth Street
Danforth, IL 60930
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 0690
The facility policy Handwashing/Hand Hygiene dated revised, August 2019 documents the following:
Level of Harm - Minimal harm
or potential for actual harm
This facility considers hand hygiene the primary means to prevent the spread of infections.
The same policy documents:
Residents Affected - Few
Policy Interpretation and Implementation
1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing
the transmission of healthcare-associated infections.
2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of
infections to other personnel, residents, and visitors.
3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily
accessible and convenient for staff use to encourage compliance with hand hygiene policies.
4. Triclosan-containing soaps will not be used.
5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use
of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted
throughout the facility.
6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: When
hands are visibly soiled; and
After contact with a resident with infectious diarrhea including, but not limited to infections caused by
norovirus, salmonella, shigella and C. difficile.
7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or
non-antimicrobial) and water for the following situations:
Before and after coming on duty;
Before and after direct contact with residents;
Before preparing or handling medications;
Before performing any non-surgical invasive procedures;
Before and after handling an invasive device (e.g., urinary catheters, IV access sites);
Before donning sterile gloves;
Before handling clean or soiled dressings, gauze pads, etc.;
Before moving from a contaminated body site to a clean body site during resident care;
After contact with a resident ' s intact skin;
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145953
If continuation sheet
Page 5 of 7
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
145953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairieview Lutheran Home
403 North Fourth Street
Danforth, IL 60930
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 0690
After contact with blood or bodily fluids;
Level of Harm - Minimal harm
or potential for actual harm
After handling used dressings, contaminated equipment, etc.;
After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;
Residents Affected - Few
After removing gloves;
Before and after entering isolation precaution settings;
Before and after eating or handling food;
Before and after assisting a resident with meals; and
After personal use of the toilet or conducting your personal hygiene.
8. Hand hygiene is the final step after removing and disposing of personal protective equipment.
9.The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with
routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
10. Single-use disposable gloves should be used:
before aseptic procedures;
when anticipating contact with blood or body fluids; and
when in contact with a resident, or the equipment or environment of a resident, who is on contact
precautions.
The same policy documents:
Applying and Removing Gloves
1. Perform hand hygiene before applying non-sterile gloves.
2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff.
3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside
out.
4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and
folding it into the first glove.
5. Perform hand hygiene
The facility Policy Perineal Care updated 9/28/23 (day of survey) documents the following:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145953
If continuation sheet
Page 6 of 7
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
145953
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/29/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairieview Lutheran Home
403 North Fourth Street
Danforth, IL 60930
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 0690
Purpose.
Level of Harm - Minimal harm
or potential for actual harm
The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections
and skin irritation, and to observe the resident 's skin condition.
Residents Affected - Few
Steps in the Procedure
1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached.
2. Wash and dry your hands thoroughly.
3. Fill the wash basin one-half (1/2) full of warm water, if using. Place the wash basin or packaged wipes on
the bedside stand within easy reach.
4. Fold the bedspread or blanket toward the foot of the bed.
5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet.
6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident ' s body.
7. Put on gloves.
8. Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as
necessary.
For a female resident:
a. Wet washcloth and apply soap, if using.
b. Wash perineal area, wiping from front to back.
(1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling
catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently
rinse and dry the area.)
(2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in
same direction, using fresh water and a clean washcloth, if using soap.
(3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the
leg to avoid traction or unnecessary movement of the catheter.
(4) Gently dry perineum.
c. Ask the resident to turn on her side with her top leg slightly bent, if able.
d. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the
buttocks.
e. Rinse and dry thoroughly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145953
If continuation sheet
Page 7 of 7
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
10 citations 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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0133GeneralS&S Epotential for harm
Install a two-hour-resistant firewall separation.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the September 29, 2023 survey of PRAIRIEVIEW LUTHERAN HOME?
This was a inspection survey of PRAIRIEVIEW LUTHERAN HOME on September 29, 2023. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PRAIRIEVIEW LUTHERAN HOME on September 29, 2023?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.