Health inspection·August 4, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review the facility failed to maintain dignity and respect during dining observation for one of one resident (R99) reviewed for resident rights in a sample of 25. Residents Affected - Few Findings include: On 8/1/2023 at 12:15pm V20 (Certified Nursing Assistant-CNA) was observed standing over R99 assisting with feeding a meal. On 8/1/2023 at 12:18pm V20 said we don't have any chairs in this dining room, yes, I should be sitting down while assisting with meals. On 8/1/2023 at 2:30pm V3 (Director of Nursing-DON) said I expect all staff to respect the residents and have a seat while assisting with meals. A Care-plan dated 10/31/2022 R99 requires a mechanical soft diet. Facility Policy: Resident Rights Protocol for all Nursing Procedures 1. Prior to having direct-care responsibilities for residents, staff have appropriate in-service training on resident rights including: a. Resident dignity and respect: Page 1 of 12 145629 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one (R70) out of seven residents reviewed for accommodation of needs in a sample of 25. Residents Affected - Few Findings Include: On 08/02/23 at 11:15 AM, R70 was observed sitting in her wheelchair. Her call light was on the floor and not within her reach. On 8/2/2023 at 11:20 AM, V24 (CNA) observed that R70 call light was on the floor and not within the reach of R70. V24 said that the call light should be within R70's reach. On 8/2/2023 at 11:22 AM, V16 (Licensed Practical Nurse) said that call light should be within R70 reach. On 8/3/2023 at 12:00 PM, V3 (Director of Nursing) said that the call light within the resident's reach. R70 is an 86 years female admitted on [DATE] with diagnosis not limited to acute or chronic diastolic (congestive) heart failure, difficulty in walking, major depressive disorder, and acute kidney failure. R70 care plan dated 6/20/2022 documents: Keep call light in reach at all times. Facility Call Light Policy Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 145629 Page 2 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop individualized comprehensive care plan to resident to meet his medical, nursing, and physiological needs in the facility. This deficiency affects one (R232) of three residents in the sample of 25 reviewed for Resident's comprehensive care plan. Findings include: On 8/1/23 at 10:50am, V15 LPN and V16 LPN said that R232's has indwelling catheter, biliary drainage, and on contact isolation for Clostridium difficile (C. Diff) infection. Observed R232's lying in bed. On 8/2/23 at 12:33pm, Review R232's medical record with V5 MDS (Minimum Data Set)/Care plan Coordinator. R232 is admitted on [DATE] with diagnosis listed in part but not limited to Calculus of gallbladder status post cholecystectomy, Urinary retention, Diabetes Mellitus type 2, Clostridium Difficile colitis. Physician order sheet indicated: Insulin lispro 4 units subcutaneous with meals four times a day to manage blood glucose. Heparin solution 5,000 units subcutaneous three times a day for clot management. Indwelling catheter care every shift. Change for blockage or leaking. Biliary drain: cleanse site with soap and water, apply split sponge dressing every 48 hours and PRN. Flush with 10ml of normal saline every 48 hours. Do not aspirate. Review R232's comprehensive care plan with V5 MDS/Care plan Coordinator. V5 said that there is no care plan for R232 regarding his contact isolation for C. diff, indwelling catheter usage, insulin usage, biliary drainage care and heparin injection usage. V5 said that they overlook in formulating comprehensive care plan for R232's addressing his medical needs. V5 said that interim care plan is formulated within 24 hours upon admission and comprehensive care plan is formulated within 14 days upon admission. Facility's policy on Comprehensive Care plan indicates: Policy: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and or psychological needs is developed for each resident. Policy specification: 3. Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas b. Incorporate risk factors associated with identified problems e. Identify the professional services that are responsible for each element of care f. Aid in preventing or reducing declines in the resident's functional status or functional levels g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program as needed 145629 Page 3 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0656 i. Reflect the resident's needs and preferences and align with the resident's cultural identity. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145629 Page 4 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow its policy on medication safety by finding medications without physician order at resident's bedside. This deficiency affects one (65) of three residents in the sample of 25 reviewed for Resident's safety. Residents Affected - Few Finding include: On 8/1/23 at 12:38pm, Observed R65 lying in bed. Observed the following medications at R65's bedside tray table in front of him namely: Diaper rash ointment (Desitin cream), Zinc oxide ointment, hemorrhoidal ointment, Hydrocortisone cream ([NAME] eczema cream), Neuropathy cream, and Diaper rash cream (Riley's butt cream) labeled for another resident's name. R65 said that these are all his medications, and he is using it. He said that his daughter brought these medications several weeks ago and applied when she comes to visit. Called V16 LPN to R65's room and showed the medications at bedside tray table. V16 said that medications probably brought by his family. V16 said that R65 should not have medications at bedside without order from the physician. V16 said that Diaper rash cream (Riley's butt cream) belongs to a discharged resident. V16 said that she will remove all the medications and will give it to V3 DON. On 8/1/23 at 2:10pm, Informed V3 DON of above observation. V3 said that R65 cannot have medication at bedside without physician order. V3 said that R65 cannot use treatment medication of another resident. Facility's policy on Medication administration indicates: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures: B. Administration 2) Medications are administered in accordance with the written order of the prescriber 14) Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 15) Medication supplied for one resident are never administered to another resident. 145629 Page 5 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to monitor the low air loss mattress is functioning properly on a resident who has multiple stage 4 and unstageable of pressure ulcers. The facility also failed to follow the manufacturer recommendation of avoiding multiple layers of linens over the Low Air Loss mattress. This deficiency affects one (R122) of three residents in the sample of 25 reviewed for Pressure ulcer Management. Residents Affected - Few Findings include: R122 is re-admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Metabolic Encephalopathy. Physician order sheet indicated: Pressure reducing mattress continuous. Care plan indicated: R122 has pressure ulcers noted at re-admission, and is at risk for slow, no healing of wound and further breakdown related to immobility, CVA (cerebrovascular accident) with left hemi, Diabetes, Anemia, Chronic Kidney disease and Protein calorie malnutrition. Wound report dated 7/31/23 indicated: 1) Left thumb- stage 2 Pressure Ulcer (PU), dated identified-7/26/23, 1.5x1.5x0.1cm. 2) Sacrum- stage 4 PU, date identified-7/19/23, present on admission, 12.8x7.5x0.3cm. 3) Left thigh posterior ischial- stage 2 PU, date identified-7/19/23 , present on admission 0.2x0.2x0.1cm. 4) Left top of foot lateral foot- necrotic PU , date identified -7/19/23, present on admission, 5x2cm. 5) Left ankle- necrotic PU, dated identified-7/19/23, present on admission, 3x3cm. 6) Left lateral heel- necrotic PU, date identified-7/19/23, present on admission, 5x6.8cm. 7)Right top of foot bunion area- PU, date identified-7/19/23, present on admission, 1.5x1cm. 8) Right top of medial foot-PU, date identified-7/19/23, present on admission, 2x2cm. 9) Right ankle medial malleolus-PU, date identified-7/19/23, present on admission, 1x2.5cm. On 8/2/23 at 11:05am, Observed R122 lying in Low Air Loss mattress with booster on each side of the bed attached. Noted Low Air Loss mattress control unit located at the foot part of the bed is off. V9 Wound Care Nurse (WCN) and V19 Wound Care Physician (WCP) preparing for wound dressing of R122 while V18 CNA is preparing R122 for wound care. On 8/2/23 at 11:15am, Before V9 WCN and V18 CNA trying to reposition R122 for wound care, informed them of Low Air Loss mattress control unit is off. V9 checked on the control unit and the cord connected to the mattress. The control unit does not have lit on. V9 said that the cord is not properly connected. V9 corrected it and the Low Air Loss mattress control unit turns on. V9 and V18 repositioned R122 to his side, observed bath blanket folded in quarter underneath R122. Informed V9 of observation made. V9 said that R122 should only be on flat sheet over the Low Air Loss mattress. V9 educated V18 that only flat sheet is placed for resident on Low Air Loss mattress, no multiple layers of linen. V9 WCN provided wound care to R122 assisted by V19 WCP and V18 CNA. On 8/2/23 at 11:47am, V9 WCN said that she expected the staff - nurses and CNAs to monitor residents on Low Air Loss mattress control unit is on and it's functioning properly. V9 said that no multiple layer of linens is placed on Low Air Loss mattress, only flat sheet. On 8/2/23 at 11:50am, V18 CNA said that she is did not check this morning if R122's Low Air Loss mattress control unit is on and it's functioning properly. On 8/3/23 at 9:50am, V9 WCN said that she did gave in-services to staff regarding: monitor function 145629 Page 6 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0686 of low air loss mattress and proper linen on low air low mattress yesterday and gave copy of the in-service meeting done. Level of Harm - Minimal harm or potential for actual harm Facility's policy on Pressure /Skin Breakdown-Clinical Protocol indicates: Residents Affected - Few Policy specification: 7. The physician will authorize pertinent orders related to wound treatments including pressure redistribution surfaces, wound cleansing and debridement approaches, dressing (occlusive, absorptive etc.) and application of topical agents. Facility's policy on Support Surface Guidelines indicates: Purpose: To provide guidelines for the assessment of appropriate pressure reducing and relieving devices for the residents at risk of skin breakdown. General Guidelines: 1. Pressure-reducing and pressure-relieving devices are to promote comfort for all bed-or chair bound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Assessment: 1. Any individual at risk for developing pressure injuries should be placed on a pressure-reducing device such as foam, static air or alternating air when lying in bed. Intervention/Care strategies 1. Any individual at risk for developing pressure injuries should be placed on a pressure-reducing device such as foam, static air or alternating air when lying in bed. Facility provided copy of Low air loss mattress manufacturing guideline indicated: Step 2. Cover the mattress with a cotton sheet. 145629 Page 7 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to complete smoking assessment of resident upon admission who has history of conviction of arson. This deficiency affects one (R87) of three resident reviewed for Smoking Safety management. Findings include: On 8/1/23 at 11:00am V15 LPN and V16 LPN said that R87 is a smoker. On 8/1/23 at 1:22pm, Observed R87 propelling himself in the 1st floor unit. He said that he smokes without supervision. On 8/3/23 at 11:36am, Review R87's medical records with V11 Director of Social Services. R87 is admitted on [DATE]. Care plan indicated that he is identified offender. He was convicted of Arson in 1983 and retailed theft in 1987. Resident was assessed to be at risk for aggression based on this facility's aggression assessment. V11 said that she did not complete R87's smoking assessment upon admission. She completed it only when requested for it on 8/1/23. She said it was not done because she was on vacation when R87 was admitted . Facility's policy on Resident's smoking indicates: Purpose: To establish guidelines to prohibit smoking by residents and visitors in the building except in designated areas. To establish guidelines for the specific circumstances I which residents may smoke in the designated areas and when increased supervision is required. Policy Specifications: 1. All residents who desire to smoke will be assessed by the interdisciplinary team to determines if the individual is appropriate for independent smoking. 145629 Page 8 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to secure catheter tubing for one resident (R40) of three residents reviewed for catheters in the sample of 25. Residents Affected - Few Findings include: On 8/1/23 at 1:16 PM R40's indwelling urinary catheter was draining clear violet colored urine in the tubing. The urine in the collection bag was dark and brownish tinted. The catheter tubing is not secured to the resident's leg or body. On 8/1/23 at 1:20 PM V5 (Registered Nurse) said the catheter should be attached. On 8/1/23 at 1:50 PM V25 (Licensed Practical Nurse) said the catheter should be attached. She could pull on it. R40's wound care notes indicate that she has a Stage IV pressure ulcer on the sacrum. R40's Care Plan indicates that she requires indwelling (urinary) catheter R/T (related to) sacral wound. Policy: (Urinary) Catheter Insertion, Female Resident Revised August 2008 Steps in the Procedure 21. Attach catheter to drainage tubing. Tape catheter to inner thigh or secure with leg band. Secure drainage tubing to bottom bed sheet with clip from drainage set. 145629 Page 9 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on observation, interview and record review the facility failed to follow its policy by failure to obtain physician order prior to provide hospice care services and resident's hospice medical records available and accessible to all interdisciplinary staff. This deficiency affects one (R108) of three resident in the sample of 25 reviewed for Hospice Care Services. Findings include: On 8/1/23 at 11:00am, V15 LPN and V16 LPN said that R108 is on hospice care services. V16 said the hospice binder or folder usually by the nursing station but she cannot find it. Observed R108 lying in bed with oxygen via nasal cannula. On 8/1/23 at 12:48pm, V16 LPN provided R108's hospice folder which includes admission orders dated 7/26/23, Interdisciplinary (IDT) Plan of care revision/Physician orders dated 7/27/23, Interdisciplinary Care plan/initial general POC (Plan of care) dated 7/26/23 and IDT visit logs dated 7/27/23, 7/28/23 and 7/31/23. No documentation included of what hospice services has provided to R108. On 8/1/23 at 1:03pm, Showed to V3 DON R108's hospice medical records. V3 said she is not familiar of what hospice medical records should be included in R108's hospice folder. Requested for facility's hospice care services policy. On 8/3/23 at 11:36am, V11 Director of Social Services said that she is not responsible for coordinating resident's hospice care medical records. V11 referred to admission or Nursing department. On 8/3/23 at 1:31pm, V14 Director of admission said that she is only responsible for coordinating contract between facility and hospice service. She does not coordinate hospice medical record on resident's chart. V14 referred to social services. On 8/3/23 at 2:10pm, Review facility's hospice policy with V3 DON. Informed V3 that R108 was admitted to hospice care on 7/26/23 per hospice care documentation, but facility only obtained physician order on 8/1/23 after surveyor reviewed the chart. Informed V3 that no communication of pertinent records of hospice IDT that visited R108 from 7/27/23 to 7/31/23 such as progress notes indicating services rendered to R108. V3 said that she informed the hospice care provider to email the hospice progress notes of R108. V3 presented email from hospice care provider sending R108 nurses notes dated 8/3/23. Facility's policy on Hospice services indicates: Policy: To honor the advance directives and care alternatives residents may desire when terminally ill and to afford residents with care that allows for dignity and comfort during the end stage of their lives. The facility will provide hospice services either directly or through arrangements with a qualified service provider. Standards: 1. Residents will be provided hospice are upon physician's order indicating need and related terminal illness diagnosis has been documented. The physician will confirm the need for hospice service at 145629 Page 10 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0849 least every 6 months by signing the re-cap physician order indicating same. Level of Harm - Minimal harm or potential for actual harm 6. All hospice service staff will write a progress note for each resident visit indicating treatment provided and pertinent related to the resident's condition which is available in the medical record for all interdisciplinary staff to access. Residents Affected - Few Hospice services agreement provide for R108 in Nursing facility indicates: 7. Communications concerning hospice patient. The parties will communicate pertinent information with each other either verbally or in the hospice patient's record at least weekly at each hospice visit to ensure that the needs of each Hospice patient are addressed and met 24 hours/day. Documentation of such communication shall be included in the Hospice Patient's medical record. 11. Clinical Records and Discharge Summary. Hospice and facility shall each prepare and maintain complete and detailed clinical records concerning the Hospice patient receiving Facility room and board services under this agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state law and regulations and applicable Medicare and Medicaid program guidelines. Each clinical record shall and completely promptly and accurately document all services provided to and events concerning the hospice patient (including evaluations, treatments, progress notes, authorization for admission to hospice and facility and physician orders entered pursuant to this agreement) as required by this agreement. 145629 Page 11 of 12 145629 08/04/2023 Prairie Manor Nrsg & Rehab Ctr 345 Dixie Highway Chicago Heights, IL 60411

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to perform hand washing after taking care of resident who is on isolation for clostridium difficile (C. Diff) infection. This deficiency affects one ( R232) of three residents in the sample of 25 reviewed for Infection control protocol. Residents Affected - Few Findings include: On 8/1/23 at 11:30am, V10 Director of Rehab Services (DRS) observed donning PPE (Personal Protective Equipment) prior entering R232's room. V10 said that R232 is on contact isolation for C. diff. V10 said that she will provide therapy at bedside- toileting transfer. At 11:50am, Observed V10 DRS removed his PPE without performing hand washing and exited the room. V10 sanitized her hands using the alcohol-based hand rubs (ABHR) by the hallway. Informed V10 of observation made that she did not perform hand hygiene after removing the PPE and exiting R232's room. V10 said that she usually does not wash her hands inside the resident's room. V10 said she washed her hands at the nursing station. On 8/1/23 at 12:25pm Informed V3 DON of above observation. V3 said that after removing the PPE in isolation precaution room, staff should be washing their hands before leaving the resident rooms especially in C. Diff precaution. Facility's policy on Clostridium Difficile indicates: Purpose: to provide guidelines for the care of persons with diarrhea associated with Clostridium difficile (C. Diff) and to prevent transmission of C. Diff to others. General Guidelines: 6. Steps toward prevention and early intervention include: c. Handwashing of staff and residents. Facility's policy on Handwashing/Hand hygiene indicates: Policy: To assure staff practice recognized hand washing/hand hygiene procedure as a primary means to prevent the spread of infections among residents, personnel, and visitors. Alcohol based hand runs (ABHR) can be used for hand hygiene when hands are not visible soiled or contaminated with blood or bloodily fluids. Policy Specifications: 2. Facility staff should perform hand washing using antimicrobial or non-antimicrobial soap under the following conditions: b. After known or suspected exposure to Clostridium Difficile or Noro virus during an outbreak. 6. The use of gloves does not replace compliance with handwashing /hand hygiene procedure. 145629 Page 12 of 12