Health inspection·June 17, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to implement identified resident specific fall interventions for three residents (R2, R3, and R4) out of four residents reviewed for falls in a sample of 15. Findings Include: The facility's fall and fall risk, managing policy dated 8/2008 documents 1. The staff, with input of the attending physician, will identity appropriate interventions to reduce the risk of falls. 6. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling. R2's current care plan documents Resident at risk for falling related to a diagnosis of cerebral vascular accident, osteoarthritis, Atrial fibrillation, and muscle wasting. Keep call light in reach at all times. R2's medical record documents R2 has had a fall on 6/4/23. R2's medical record dated 6/4/23 documents Upon arriving for shift, writer was told resident is on the floor. Writer went in and completed head to toe assessment, resident was laying on his back on the floor next to his bed. When asked how he got on the floor, resident stated I pulled myself out the bed to go to the bathroom. On 6/17/23 at 9:10 AM, R2 observed lying in bed with his call light on the floor near the wall at the head of the bed and not within reach of the resident. R3's current care plan documents (R3) is at risk for falling related to a diagnosis history of anxiety, cerebral vascular accident, Hemiplegia, peripheral vascular disease, weakness and his preference of sitting on side of bed at times. place 'call, don't fall sign as visual reminder to use call light. Floor mats next to bed on right side when in bed. Keep call light in reach at all times. On 6/17/23 at 9:02 AM, R3's observed lying in bed with his call light lying on the floor at the head of the bed next to the wall and floor mat propped up against the wall next to the bathroom. R3 stated I use me call light because I need help getting to the bathroom and transferring to my wheelchair, but I can't reach it right now. It's back there on the floor. R4's current care plan documents (R4) is at risk for falling related to a diagnosis of Hemiplegia, weakness to left side, urinary tract infection and hepatitis. Call light labeled with yellow tape to ensure viability. Place call light on resident's right side when possible due to left side deficit. Keep call light in reach at all times to right side. Bilateral floor mats. Apply bolsters to bed to define perimeters and assist with proper body alignment. R4's medical record documents R4 had a fall on 3/14/23. R4's medical record dated 3/14/23 documents Observed resident sitting on floor on buttocks in front of wheelchair. When asked what happened, resident said, I was trying to sit up in my chair. wheelchair was unlocked resident slid to floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145629 If continuation sheet Page 2 of 3 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 145629 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411 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 On 6/17/23 at 9:02 AM, R4 lying in bed with the head of the bed raised in a sitting position. R4's call light is on the bed frame behind the mattress and not within resident's reach. There are fall mats and bolsters lying propped up against the wall and not in place next to or on R4's bed. R4 stated Can you help me? I can't reach my call light. I need some help. On 6/17/23 at 9:16 AM V4, Licensed Practical Nurse (LPN) stated The call light should be within the residents reach. On 6/17/23 at 9:18 AM upon entering the room with V4, LPN, R4 has his legs over the side of the bed and appears to be attempting to get out of bed. V4, LPN, assisted R4 back to bed and retrieved R4's call light from behind the bed. On 6/17/23 at 2:20 PM, V2, Director of Nursing (DON), stated The call lights are on the care plans because we want them to call us for help instead of getting up on their own. (R4)'s fall mats and bolsters should be in place when he's in bed. It's part of his fall risk prevention due to his seizure activity and he likes to get out of bed on his own. He also like to sit at the edge of the bed as well. No one's floor mats should be propped up against the wall when they're in bed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145629 If continuation sheet Page 3 of 3