Health inspection·July 30, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 protect the resident's right to be free from abuse by failing to prevent misappropriation of a resident's narcotic pain medication. This failure affected one of three residents (R4) reviewed for abuse in the sample of six. Residents Affected - Few Findings Include: The Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 12/23/21 documents the term Abuse can includes misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The Incident Report for incident of 7/12/24 documents R4 had an order for Hydrocodone (Opioid) to be taken every 6 hours. On 7/12/24, V9 Registered Nurse contacted Hospice to attempt to refill the Hydrocodone. At that time there were only 26 tablets remaining. V12 Hospice Nurse informed V9 that a refill of 60 Hydrocodone was delivered to the facility on 7/3/24. Upon an initial investigation, it was determined that 60 tablets of R4's Hydrocodone were missing, along with the corresponding Controlled Drug Received/Record/Disposition Form. Based on the facility's investigation, it is believed that V5 Agency Registered Nurse stole 60 tablets of R4's Hydrocodone and the corresponding Controlled Drug Received/Record/Disposition Form. R4's Physician Order Sheet dated July 2024 documents R4 is diagnosed Alzheimer's Disease, Dementia, Behavioral Disturbance, Mood Disturbance, Anxiety, Seizures, Major Depressive Disorder, Heart Disease, and Muscle Weakness. R4's Physician Order dated 4/24/24 documents R4 was prescribed Hydrocodone-Acetaminophen 5-325 (Opioid) milligrams (mg) by mouth four times a day for pain. R4's Minimum Data Set, dated [DATE] documents R4 is severely cognitively impaired. R4 receives scheduled pain medication and uses non-verbal sounds to indicate pain. R4's Care Plan dated 7/10/24 documents R4 has the potential to experience pain. R4 is under the care of Hospice Services. R4's Controlled Drug Received/Record/Disposition Form documents on 6/26/24, the facility received 60 tablets of Hydrocodone/Acetaminophen 5-325 mg to be given to R4 four times per day. R4's Controlled Drug Received/Record/Disposition Form documents on 7/3/24, the facility received 60 (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: 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 07/30/2024 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)