Health inspection·December 2, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record Review the facility failed to properly install foot pedals (R58), identify oxygen tubing and call light cord as trip hazards resulting in a fall (R1) and properly transfer R1 following a fall. These failures affect two of six residents (R1, R58) reviewed for accidents in the sample list of 29. These failures resulted in R58's left leg fracture and R1's right hip and right arm fracture. Findings include: The facility's Fall and Fall Risk Management policy documents that staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. This policy also documents fall risk factors, including environmental factors that contribute to the risk of falls, such as improperly fitted or maintained wheelchairs and unsafe or absent footwear. 1.) On 9/5/2025, R58's nursing progress notes state: While (V25, R58's Power of Attorney) was pushing resident (R58) in wheelchair outside during fall [NAME], when resident (R58) went from cement lot to grass, R58's foot caught on ground and (V25) was unaware and continued to push wheelchair per resident. Resident (R58) denies any pain or discomfort while sitting still. (R58) states discomfort with movement. Local 2–3+ edema noted below knee. Dr. (Doctor) notified and POA (Power of Attorney) made aware. Orders received to send resident to hospital. Management made aware. On 9/29/25 at 11:05 AM, R58 was in the dining room in R58's wheelchair with foot pedals on. R58 stated that she was outside at the fall festival when V25 was pushing her wheelchair without foot pedals, and V25 pushed R58 from the pavement to the grass because there were a lot of people. R58 stated the wheelchair got stuck in the grass and her leg was caught under the wheelchair. R58 stated that no staff were outside to help. R58 was brought inside and sent to the emergency room and returned with a diagnosis of left tibial fracture in two places and small joint effusion. R58's Left Knee X-ray dated 9/5/25 documents frontal view suggesting an impaction fracture of the medial tibial plateau, and the lateral view indicates a comminuted proximal tibial fracture (shinbone near the knee). Further imaging such as computed tomography (CT) was recommended. R58's Left Knee CT dated 9/5/25 documents evaluation due to left knee pain and swelling following fall from wheelchair. CT indicated fracture of the posterior tibial plateau involving medial and lateral aspects extending anteriorly into tibial metadiaphysis. On 9/30/2025 at 1:45 PM, V15, Certified Nursing Assistant, stated R58 did not have foot pedals on when her husband took her out to the fall festival, and that R58 is supposed to have foot pedals on. On 12/2/25 at 11:00 AM, V2, Director of Nursing, stated R58 should have had foot pedals on (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 4 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 12/02/2025 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)