Health inspection·February 11, 2025

F 0583 Keep residents' personal and medical records private and confidential. 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 a resident's right to privacy for three of three residents (R1, R2, R3) reviewed for resident rights on the sample of three. Residents Affected - Few Findings Include: The Resident's Rights for People in Long Term Care Facilities dated May 2018 documents residents have the right to privacy. The facility may not give information about residents or their care to any unauthorized person without the resident's permission. 1. R1's Medical Diagnoses list dated February 2025 documents R1 is diagnosed with Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and requires staff assistance for all Activities of Daily Living. 2. R2's Medical Diagnoses list dated February 2025 documents R2 is diagnosed with Alzheimer's Disease. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired and requires staff assistance for all Activities of Daily Living. 3. R3's Medical Diagnoses list dated February 2025 documents R3 is diagnosed with Alzheimer's Disease. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired and requires staff assistance for all Activities of Daily Living. The facility's Final Investigation Report dated 1/24/25 documents on 1/20/25 the facility was alerted by V5 (employee (V4's) ex-boyfriend) that V4 Certified Nurses Assistant (CNA) had shared resident's names and some information about things that happened in V4's workday concerning residents (R1, R2, R3). V4 admitted to V1 Administrator during his investigation that she had shared details about her day with V5 on occasion and did mention resident's first names. V4 was terminated for violating the facility's confidentiality expectations. V4's Record of Counseling dated 1/23/25 documents V4 was terminated related to a violation of the facility's confidentiality policies. (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: 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 02/11/2025 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)