Health inspection·November 5, 2025

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete she does not like the sit to stand lift, but there were no transfer issues during V12's shift. On 10/28/25 at 2:42 PM, V15 LPN stated V15 was alerted to a bruise on (R1's) right chest and arm by the CNAs on 9/21/25. V15 stated V15 felt the bruise lined up with the belt on the stand lift that R1 used to transfer. V15 denied any knowledge of any incidents that could have caused R1's bruising. On 10/28/25 between 4:01 PM and 4:43 PM, V27 and V28 CNAs stated they found R1's bruising on the evening of 9/21/25 prior to transferring her to bed, which was not noted when V28 had last cared for R1 the night before. V27 stated something must have happened during the dayshift. V28 described the bruise as purple, almost black, extending from the base of R1's neck down to the bottom of R1's abdomen, across from mid chest to right under arm before the elbow. V27 stated initially R1 was a stand pivot transfer but then R1 started using the sit to stand lift a few weeks prior. V27 stated R1 disliked the stand lift, R1 would tell us that she was hurting and didn't like the lift, and to put R1 down. V27 stated R1 couldn't stand in the lift for very long, so staff had to move R1 quickly. V27 and V28 were not aware of the cause of R1's injury, or any falls or incidents that could have caused R1's injury. On 10/29/25 at 8:55 AM, V21 Memory Care Director stated V21 did not work on 9/21/25 and received a text message that evening from V15 Licensed practical Nurse reporting R1's bruising. V21 stated no one saw anything happen and staff were unsure what caused the bruising. V21 stated V15 LPN told V21 that the bruise aligned with the stand lift sling, so V21 assumed that was the cause of R1's injury. On 10/29/25 at 1:27 PM, V1 Administrator stated V1 assisted collectively with nurse management for the investigation of R1's 9/21/25 bruising/injury. V1 stated V15 LPN, and the two CNAs were interviewed for this investigation. V1 confirmed no other staff were interviewed. V1 stated the interviewed staff were asked about what happened and how R1 had been that day/evening. V1 stated the staff only talked about R1 in the sling and how she played balloon toss with a pool noodle that afternoon. V1 was asked to clarify what the staff mentioned about the stand lift sling and V1 stated meaning R1 transferred with the stand lift and sling that day. V1 said there were no reported accidents, injuries, or concerns related to the sling use. V1 confirmed staff were not asked if R1 had any falls/incidents or what caused R1's injury. V1 stated the staff report resident falls. V1 stated V1 reviewed video surveillance footage of R1 on the afternoon of 9/21/25 participating in an activity that involved using a pool noodle to strike a balloon.V1 stated based on this observation, V1 questions if R1's stretching and repetitive arm movements during the activity may have contributed to a vascular injury, such as a tear in an artery, which could potentially explain the bruising observed on R1. V1 confirmed no other video surveillance was reviewed. The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 12/23/21 documents the investigation process is used to try to determine the cause of injuries of unknown source and rule out abuse. This policy documents the designated investigator will begin the investigation immediately to implement a root cause investigation and analysis, and the gathered information is given to the administrator. The investigation may include who was involved, resident statements, roommate statements, involved staff and witness statements, a description of the resident's behavior and environment at the time of the incident. Event ID: Facility ID: 145953 If continuation sheet Page 2 of 10 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 11/05/2025 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to assess, monitor for appropriate mode of mechanical lift of four residents reviewed for injury and transfer in a sample list of ten. This failure caused delay of treatment for R1's arterial bleed which required multiple transfusions and emergency surgical repair which eventually led to R1's death.The Immediate Jeopardy began on [DATE] when R1 fell and was not adequately assessed for injury or appropriateness of initiation of sit-to-stand lift. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 2:27PM. The surveyor confirmed by observation, record review, interview that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's Hospital documentation dated [DATE] includes the following diagnoses: Generalized Anxiety Disorder, Major Depression, Alzheimer's Disease, Psychotic Disturbance, Morbid Obesity, Osteoarthritis Right Shoulder, History of Cerebral Vascular Accident with Hemiparesis and Hemiplegia, Ataxia, History of Falls, Bilateral Knee Replacement, Right Rotator Cuff Repair, Anticoagulant Use, and Right Total Hip Replacement. R1's Minimum Data Set (MDS) dated [DATE] documents R1 was totally dependent on staff for all Activities of Daily Living (ADLs). This MDS documents R1 was severely cognitively impaired. R1's Progress Note dated [DATE] at 9:29 AM documents Staff stated resident (R1) lost her balance walking to the bathroom. Stated she (R1) fell into her wheelchair and fell to the floor on her right side and turned herself to sit on her bottom. Staff stated she did not see her hit her head. Gait belt was in use. Resident was complaining of right hip pain. Full head-to-toe assessment completed. When staff assisted resident off the floor and laid her down on her bed she complained of left hip pain. Family, physician, DON (Director of Nursing) and Unit director notified of fall. Physician ordered two-view x-ray of bilateral hips and pelvis stat. (contracted in house Xray Company) was called for x-ray.R1's Progress Note dated [DATE] at 10:15AM documents Staff notified this nurse that resident (R1) had a bruise to her right ear and jaw line, also bruise to right elbow. Physician, Power of Attorney (POA), Director of Nursing (DON), and Unit Director notified.R1's Progress Note dated [DATE] at 9:32PM by V18 Restorative Nurse documents Updated transfer status as follows: Transfers with use of stand lift and two (staff) assistance. Updated the following NURSING REHAB/RESTORATIVE: Transfer Program: (R1) transfers with use of stand lift stand two staff assist PRECAUTIONS: Risk for falls, Shortness of Breath, Fatigues Easily.No measurements of the bruise are documented following the [DATE] fall and a complete baseline assessment of the injury is not documented. An assessment for safe appropriate use of the sit-to-stand lift is not documented. The Weekly Skin Assessments dated [DATE], [DATE] ,[DATE], and [DATE] make no mention of the progression of the bruise first noted [DATE]. The Weekly Skin Assessments dated [DATE] and [DATE] document only scattered bruising. No sites are documented, and no measurements are documented. The right elbow bruise is only mentioned in the [DATE] skin assessment.No progress notes are documented assessing the bruising until [DATE] at 7:09PM by V15, Licensed Practical Nurse (LPN) CNAs were putting resident to bed and noted bruising to sternum and under and across right breast and under right arm that matches up with the strap of stand lift. (R1) does have some pain 5/10 and has limited ROM to right arm. V25 Medical Director was notified and was told of bruising and that (R1) also takes blood thinners. (V25) stated that as long as there is no bleeding it's ok just to monitor area. POA (Power of Attorney) and unit director notified.On [DATE] at 5:00PM, V15 stated When I called V25, I reminded V25 (R1) was on Apixaban (anticoagulant) but he did not give me an order to hold it. V25 just said monitor and as long as there is not bleeding there are no other orders.R1's Progress Note dated [DATE] Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145953 If continuation sheet Page 3 of 10 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 11/05/2025 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few at 8:52AM documents This nurse observed more bruising to residents upper left and right chest above ribcage. Resident short of breath with activity. PRN Tylenol given, and resident requested to lay down. (V21) unit director, and V2 DON (Director of Nursing), notified. (V2) requested x-ray to be done. Notified (V25) Medical Director for order. Waiting for reply.On [DATE] at 1:02PM, documents Resident had a change of condition from this morning. She (R1) became very pale, shortness of breath, and dry heaves. More bruising was starting to appear from this morning from the sit to stand sling. (V25) notified and agreed to send her to hospital. Resident POA (Power of Attorney) notified agreed to send (R1) to hospital. Ambulance arrived at 1pm and (R1) left facility at 1:05pm. Multiple bruises to R1s right side wrapping around to her mid back, bruising to right arm and into her right armpit. Bruising starting to appear to right upper shoulder by her neck, over left shoulder, and above both ribcages. T 97.4, B/P 114/83, P 143, R 18, 98% on room air. Report given to emergency room doctor. Bed hold form went with resident to (local) hospital. On [DATE] at 9:25 AM, V16 LPN stated it was passed on in morning report on [DATE] by V15 that the CNAs had found bruising the night prior while assisting (R1) for bed, and the bruising looked consistent with the stand lift. V16 stated V15 reported there was little bruising to R1's right side, breast and back. V16 stated V16 went in to assess R1 prior to breakfast and the bruise extended midline chest to midback and right armpit down the right arm. V16 stated V16 immediately notified V25 Physician, who said he had already put Eliquis on hold and asked what more V16 wanted him to do. V16 stated V16 asked for a chest x-ray and he (V25) told her (V16) to do what she wanted. V16 stated V16 ordered a portable chest x-ray but before they got here R1's condition changed. V16 stated R1 was regurgitating, dry heaving, and short of breath, and the bruising had grown in size now extending up R1's chest along bra strap. V16 stated V16 notified R1's POA multiple times and they decided to send R1 to the hospital. V16 stated V16 watched the cameras and could see that R1 was playing balloon toss prior to the bruise being found, and R1 had no signs of pain or injury at that time. V16 questioned whether R1 bumped something while playing balloon toss. V16 stated the bruising was consistent with the sit to stand sling and staff were baffled by how the injury could have happened. V16 stated V16 had not observed R1's transfers but knows that it took two to three staff for her sit to stand lift transfers due to prior reports that R1 would not stand fully upright, knees bent and slouched putting weight on R1s armpits. V16 stated R1 had to be close to the object transferring to, such as the toilet, as R1 could not withstand distance to transfer from the toilet to the bed, so R1 had to transfer back to the wheelchair and then use stand lift to put R1 in bed. V16 stated V16 was unsure if R1 had fallen, and no falls had been reported to her. V16 stated V16 speculates that R1 fell forward while using the sit to stand lift but does not know that for sure. R1's Medication Administration Record dated [DATE] documents the 8:00AM dose of Eliquis was administered. On [DATE] at 10:13AM, V16 stated V16 went into (R1's) room and gave (R1's) medication including the Eliquis before breakfast. (R1) was still in bed then and V16 didn't see the extent of the bruises until the CNA's got (R1) out of bed.R1's CAT (Computerized Axial Tomography) report dated [DATE] states Significant soft tissue contusion and a large subcutaneous hematoma extending from lateral aspect of right shoulder into upper arm and right lateral chest wall. R1 was admitted to the hospital on [DATE] related to the results of this scan and an order for Interventional Radiology consult was written. Per [DATE] hospital record upon arrival R1's Hemoglobin was documented as 5.9 grams per deciliter with the normal range being 11.6 to 15 grams per deciliter. R1 received multiple transfusions and underwent a two vessel embolization with coils and Gelfoam to stop the bleeding into R1's chest and arm. R1's progress notes document R1 returned to the facility on [DATE] at 7:24PM. (R1) was placed on hospice and expired on [DATE]. R1's death certificate documents R1's cause (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145953 If continuation sheet Page 4 of 10 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 11/05/2025 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few of death as Metabolic Encephalopathy due to Blood Loss Amenia due to Chest Wall Hematoma. This death Certificate was signed by V25, Medical Director.On [DATE] at 2:25PM, V26 Interventional Radiologist who performed R1's procedure to stop the arterial bleeding stated I believe the injury to (R1's) chest wall was consistent with an injury caused by a sit to stand lift. I don't think there is any possibility it was caused by a foam pool noodle. The injury was caused by significant blunt force trauma to R1's chest wall. I think if I were doing a root cause analysis, I would say what could have been done sooner was (R1) could have been sent to the emergency room the night before prior to (R1) losing so much blood. I do not believe (R1) would have died quite so soon were it not for the Arterial bleed.On [DATE] at 1:49PM, V25 was interviewed by phone. V25 stated that if he had known about the extent of R1's bruise he might have held the blood thinner and had R1 sent to emergency room. V25 stated I did not see the patient. V25 stated if he states to monitor, he expects more than one assessment per 12-hour shift.R1's progress noted document R1 was discharged from the hospital [DATE] at 3:00PM. R1 expired at the facility on hospice services on [DATE]. On [DATE] at 8:55 AM, V21 Memory Care Director stated V21 was not working on [DATE] and received a message from V15 LPN that night after supper, informing V21 of R1's bruising. V21 was not aware at that time of the extent of the bruising. V21 stated no one had seen anything happen and staff were unsure what caused the bruise. V21 stated V15 said the bruise aligned with the stand lift sling, so V21 assumed that was the cause of R1's bruising. V21 confirmed V15 should have documented a measurement of the bruise. V21 stated that is something we will need to do education on. On [DATE] at 9:35 AM, V2 DON stated V15 LPN should have checked on R1 once more during the night and re-measured the bruising at that time.On [DATE] at 4:51 PM, V27 CNA stated R1's bruising was found by V28 and V27 on the evening of [DATE]. V27 stated V28 had worked the night before and it wasn't there, so something must have happened during the dayshift the day we found it. V27 stated initially R1 was a stand pivot transfer but then she started using the sit to stand lift a few weeks prior to her passing away. V27 stated R1 disliked the stand lift, and would tell us that she was hurting and didn't like the lift. V27 stated R1 would tell us to put her down. V27 stated R1 couldn't stand in the lift for very long, so staff had to move her quickly.On [DATE] at 4:43 PM, V28 CNA stated V27 and V28 found R1's bruising prior to transferring R1 to bed. V28 stated the bruising was purple, almost black, and extended from R1's neck to the bottom of the abdomen, across from mid chest to right under arm just before the elbow. V28 stated it was a pretty large bruise and V28 had not noticed the bruising when she had previously cared for R1 prior to the evening of [DATE].On [DATE] at 8:15 AM, V30 Housekeeper stated before R1 was sent to the hospital ([DATE]), it was a Sunday morning. V30 stated V30 would often give back rubs and noticed that morning that R1 had purple/red/pink bruising to the right side of her neck/collar bone area, right side of face, and left wrist. V30 stated V30 did not report this to anyone since she is just a housekeeper. V30 stated an unidentified CNA told her that R1 had fallen out of the stand lift that morning. At 10:08 AM, V30 clarified V30 was off work after [DATE] and stated the date previously mentioned must have been during the first week of September or late [DATE].On [DATE] at 12:20 PM, V44 CNA stated R1 transferred with the sit to stand lift and would complain to staff that R1 didn't like it. V44 stated staff had to tell R1 to cooperate and stand up, and sometimes R1 would not cooperate. V44 stated then we would wait for R1 to push herself up, but sometimes R1 would have her butt sticking out, knees bent slightly, and the sling underneath her armpits bearing weight. V44 stated R1 was only able to tolerate standing in the lift for short duration. V44 stated V44 had not mentioned this to any nurses or restorative nurse. V44 stated V44 had only heard that R1 had a bruise on her left side/armpit area following the August fall, but V44 did not see this bruise. V44 stated R1 would complain of R1's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145953 If continuation sheet Page 5 of 10 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 11/05/2025 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few side hurting when the stand lift belt was tightened.On [DATE] at 10:30AM, V18 Restorative Nurse stated R1 was not assessed by therapy to ensure the safety of the sit-to-stand lift. R1 stated I observed one transfer with (R1) and the sit-to-stand lift. I don't have an assessment to determine when a sit-to-stand or other lift is appropriate and the only documentation I have is an Endurance-Functional Ability Assessment. This assessment was provided and does not include safety assessment for sit-to-stand lift.On [DATE] at 8:13 AM, V20 Physical Therapist stated R1 was last on therapy caseload in 2024. At that time R1 was one or two assist and was walking. R1 was not on therapy after that as she refused whenever they would try to pick her up. V20 did not work with R1 on sit to stand lift transfers.On [DATE] at 1:51 PM, V2 DON stated V2 had nothing to provide that therapy assessed/evaluated R1's use of sit to stand lift.Facility submitted abatement plan at 9:26 PM on [DATE]. Abatement plan returned to the facility at 10:21 AM on [DATE] for revision. Received revised version at 11:53 AM. Returned for revisions 12:13 PM. Received final revised version 12:32 PM. Notified facility that abatement plan was accepted 1:08 PM.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. For those residents found to have been potentially affected by the alleged deficient practice, the following corrective action was implemented:a. Nursing leaders and Administration met on [DATE] to review a plan to remediate the Immediate Jeopardy as was placed on the Facility on [DATE] at approximately 14:15. Completed [DATE].b. A Lift Assessment (Attachment A) will be conducted on all residents who require the use of a mechanical lift. This will be completed by the Restorative Nurse and Therapy Staff by the end of [DATE]. completed [DATE]c. Education will be provided to the nursing staff regarding the use of mechanical lifts and the new assessment process. This will be initiated by the Nurse Educator by the end of [DATE] and completed by [DATE]; all staff working the floor will be required to sign off on the in-services and staff not in attendance will be contacted to complete this in- service by the end of the week. [DATE] Initiated [DATE]. Ongoing. On [DATE] at 2:08PM, V2 verified through review of sign-in sheet and staff schedule all staff scheduled for night shift [DATE] were not in-serviced. V1 and V2 also verified going forward all staff will receive the training as the removal plan states prior to working on the floor. d. If a CNA is performing a mechanical lift process and feels that the lift process is unsafe, the CNA will report this to the charge nurse. The charge nurse will then immediately assess and may downgrade the mechanical lift at that point in time. This will then be reviewed by DON / ADON / Restorative Nurse / and Therapy. This education will be provided by the Education Nurse and initiated on [DATE] and completed by [DATE]; all staff working the floor will be required to sign off on the in-services and staff not in attendance will be contacted to complete this in-service by the end of the week. Initiated [DATE].On [DATE] at 2:08PM, V2 verified through review of the sign-in sheet and staff schedule all staff scheduled for the night shift on [DATE] were not in-serviced. V1 and V2 also verified going forward all staff will receive the training as the removal plan states prior to working on the floor. e. The Restorative Nurse will seek to obtain her Certification of Restorative Nursing by the [DATE]. Therapy Staff will oversee the Restorative Nursing programs until this certification has been obtained. Initiated [DATE].f. Policies are being updated regarding the monitoring of bruising for all residents on anti- coagulant therapy medication that if a new bruise is identified, the MD will immediately be notified and then the nurse on duty will monitor and reassess the bruise hourly times four hours, then every four hours for the remaining initial 24 hours, then every shift for six days. Measurements will be taken and recorded. Any signs of the bruise increasing in size within this immediate time frame will be reported to the MD by the attending nurse. A Progress Note will be completed by the attending nurse to include measurements, vital signs, and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145953 If continuation sheet Page 6 of 10 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 11/05/2025 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)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete description of the bruising and/or change of condition. This policy revision will be completed, and nurses will be in-serviced on the policy by the end of the day on [DATE]. Verified [DATE].g. The TAR was updated on [DATE] for all residents who are currently on an anti- coagulant medication: Observe for adverse reactions of ANTICOAGULANT therapy every shift: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath (SOB), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs (v/s). Verified in place [DATE]. 2. The following systematic changes have been implemented.a. The Lift Assessment will be completed for all residents who need a mechanical lift upon admission, quarterly, or as needed if their transfer status is changed. This will be completed by the Restorative Nurse and Therapy Staff by the end of the day on [DATE]. Verified [DATE].b. Following the change in a lift status, DON / ADON / Restorative Nurse or Designee will monitor and reassess three times a week for two weeks. Initiated [DATE]. Ongoing.c. If a resident shows signs of bruising and is on an anti-coagulant, the MD will immediately be notified and then the nurse on duty will monitor and reassess the bruise hourly times hours, then every four hours for the remaining initial 24 hours, then every shift for six days. If bruising increases and/or there are signs of a change in condition, the MD will immediately be notified. Initiated [DATE].d. All above education will be provided by the Education Nurse initially beginning on [DATE], for all new hires, and then monthly for three months. Initiated [DATE]e. Random audits on mechanical lift transfers will be conducted by the Nurse Leadership weekly for 12 weeks. [DATE] the form was provided. Confirmed with V2 she will be completing the audits.f. Random audits on nursing documentation regarding residents who are on anti- coagulant medications will be completed by nursing leaders weekly x 12 weeks, to ensure proper orders are in place and appropriate follow-up for signs/symptoms of adverse reactions are documented. [DATE] form provided. Confirmed with V2 she will be completing the audits.3. The following Quality Assurance Programs have been implemented:a. Lift Assessments and Transfer Status' will be added to the IDT weekly QA reporting for review. This will be presented by the Restorative Nurse and/or Therapy. Verified [DATE].b. Any injuries noted in relation to a transfer with a mechanical device will be reviewed in the daily QA meeting with the IDT. This will be presented by the IDT Nurse Leaders. Verified [DATE]. Confirmed with V2 she will be responsible for this.c. Residents on anti-coagulants and with new bruising will be added to the IDT daily QA reporting for review by the IDT Nursing Leaders. Verified [DATE]. Confirmed with V2 she will be responsible for this.d. Any incidents regarding the monitoring of residents on anti-coagulant medications will be reviewed at the daily QA meeting with the IDT and presented by the IDT Nurse Leadership. [DATE] Confirmed with V2 she will be responsible for this. Event ID: Facility ID: 145953 If continuation sheet Page 7 of 10 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 11/05/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to safely transfer a resident (R7) resulting in a fall and failed to investigate this fall for one of four residents (R7) reviewed for accidents in the sample list of 10. On 10/27/25 at 10:14 AM, R7 stated R7 had a recent fall while trying to get into bed with staff assistance. R7 stated a gait belt was not used during this transfer. R7's Minimum Data Set, dated [DATE] documents R7 as cognitively intact, R7 requires partial/moderate staff assistance for chair/bed transfers, and R7 had two or more falls without injury since the prior assessment. R7's Care Plan dated 8/26/24 documents R7 is at risk for falls, R7 has a transfer restorative program due to weakness and R7 transfers with one assist, gait belt, and grab bar or walker. R7's Endurance-Functional Mobility assessment dated [DATE] documents R7 transfers with one assist with use of gait belt, grab bar or walker. R7's Nursing Note dated 9/4/2025 at 8:22 PM documents R7 was being assisted into bed from his wheelchair, R7 let go of the bed rail, R7's knees weakened and R7 was assisted to the floor. R7 did not sustain any injuries. The post fall intervention was to use two assist for transfers in/out of bed. The Accident Investigation/Interview Form dated 9/4/25 documents V19 Certified Nursing Assistant (CNA) assisted R7 with transfer from wheelchair to bed, R7 let go of the railing, R7's knees became weak, and R7 was lowered to the floor. This form does not document whether a gait belt was used. There is no documentation that this fall was thoroughly investigated. On 10/27/25 at 1:18 PM, V2 Director of Nursing stated the nurse documented R7's fall in the 9/4/25 nursing note but didn't complete an incident report. V2 confirmed there was no fall investigation packet completed for this fall. On 10/27/25 at 3:09 PM, V19 CNA confirmed V19 assisted R7 during the fall on 9/4/25. In reference to this fall, V19 stated V19 transferred R7 from the bathroom into the wheelchair and V19 was in the process of transferring R7 into bed. V19 stated R7 went to grab the siderail on his bed, R7 let go with one of his hands to grab his pants while standing, R7 lost his balance and fell. V19 stated at that time R7 was a one assist for transfers. V19 stated V19 did not use a gait belt during this transfer. On 10/28/25 at 3:58 PM, V18 Licensed Practical Nurse confirmed V18 completed R7's Endurance-Functional Mobility assessment dated [DATE] and confirmed R7's transfer status at that time was one assist and gait belt. V18 stated staff would also have R7 use the grab bars in his bathroom, on recliner, and on bed, and/or wheeled walker. The facility's undated Managing Falls and Fall Risk policy documents: 1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g. (for example), dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Event ID: Facility ID: 145953 If continuation sheet Page 8 of 10 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 11/05/2025 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)

F 0711 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Based on interview and record review the facility failed to have the physician document and sign progress notes for each visit for five of six residents (R1, R2, R5, R9, R10) reviewed for physician visits in the sample list of 10. 1.) R1's undated Face Sheet documents R1's primary physician as V25. R1's Progress Notes, recorded by V10 Licensed Practical Nurse, document V25 evaluated R1 on 6/27/25, 8/22/25 and 9/9/25. As of 11/3/25, R1's electronic medical record (EMR) did not include any Physician Progress Notes by V25. 2.) R2's undated Face Sheet documents R2's primary physician as V25. R2's Progress Notes, recorded by V10, document V25 evaluated R2 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, R2's EMR did not include any Physician Progress Notes by V25. 3.) R5's undated Face Sheet documents R5's primary physician as V25. R5's Progress Notes, recorded by V10, document V25 evaluated R5 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, R5's EMR did not include any Physician Progress Notes by V25. 4.) R9's undated Face Sheet documents R9's primary physician as V25. R9's Progress Notes, recorded by V10, document V25 evaluated R9 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, R9's EMR did not include any Physician Progress Notes by V25. 5.) R10's undated Face Sheet documents R10's primary physician as V25. R10's Progress Notes, recorded by V10, document V25 evaluated R10 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, R10's EMR did not include any Physician Progress Notes by V25. On 11/4/25 at 8:10 AM, V2 Director of Nursing stated the physician visit notes are documented under the assessments or uploaded into the resident's EMR in the miscellaneous section. V2 stated sometimes they have to request for the physician to send them to the facility. At this time V25's Progress Notes were requested for R1, R2, R5, R9 and R10. At 9:55 AM, V2 stated V2 had to request V25's Progress Notes. On 11/4/25 at 1:49 PM, V25 stated V25 sees each resident at least every 60 days, tries to open a progress note at the time of each visit and tries to have an office day to complete the visit notes, but that doesn't always happen. Event ID: Facility ID: 145953 If continuation sheet Page 9 of 10 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 11/05/2025 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)

F 0944 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on interview and record review the facility failed to ensure all staff were trained on the facility's Quality Assurance Performance Improvement Program. This failure affects all 84 residents in the facility. The facility's Facility assessment dated as reviewed 9/26/25 includes staff education/training upon hire and annually through (web-based training and education system), new employee orientation, and in-services. This Facility Assessment does not include QAPI training as one of the topics that staff will be trained on. On 11/4/25 at 10:55 AM, employee education and training were reviewed with V48 Human Resources and V48 was asked about QAPI training. V48 confirmed there was no documentation of QAPI training in the (web-based training and education system) or as part of the facility's new employee orientation training. V48 stated V48 will have to follow up with V33 Nurse Educator to see if there is any training on QAPI. At 12:35 PM, V48 stated QAPI training has not been completed since 2020. On 11/4/25 at 1:16 PM, V33 Nurse Educator confirmed QAPI training has not been completed. V33 stated V33 just added QAPI training in (web-based training and education system) for all staff and the staff have a week to complete it. The facility's Resident Roster dated 10/27/25 documents a census of 84 residents. Event ID: Facility ID: 145953 If continuation sheet Page 10 of 10