Health inspection·August 22, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to prevent an incident of resident-to-resident physical assault. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 attacking R1 unprovoked with a belt to R1's leg. R1 being a severely cognitive resident it is reasonable to conclude this resulted in R1 suffering psychological feelings of fear after being attacked by R2. The Findings include: R1 has diagnosis including but not limited to Dementia, Major Depressive Disorder, Alzheimer's Disease, Generalized Anxiety Disorder, and Weakness. R1's cognitive assessment dated [DATE] is a 6, severely impaired. R2 has diagnosis including but not limited to Unspecified Dementia and Alzheimer's Disease. R2's cognitive assessment dated [DATE] is a 0, severely impaired. On 8/15/23 at 10:49AM R1 observed in the dining room but did not provide statement. On 8/15/23 at 11:28AM V1, Licensed Practical Nurse (LPN), said during the night shift in the morning hours, V7, Certified Nursing Assistant (CNA), called me I was passing medications. V7 said R2 is on the floor. She said R2 was in the room of another patient. V1 said R2 was agitated. V1 said R2's lip was bleeding, and she was trying to administer care and R2 grabbed my hand and twisted it backwards and he was twisting my legs around his. V1 said R2 is very strong he just kept bending my right hand. V1 said this is the second time he attacked me. V1 said the first time he pulled down my pants. He had been refusing to get out of a patient room. I was trying to get him out and he grabbed my pants and pulled them down. V1 said R2 twisted my right wrist. V1 said the first time he attacked me was earlier this year. V1 said R2 gets confused around 5:00 or 6:00PM. V1 said in the mornings he was very combative, and it seems like the medicine has worn off and you can't control and reason with him. V1 said R2 needs constant redirection because he goes into others' rooms and lays in other peoples' beds. V1 said all I saw was R2 was on the floor on his side talking gibberish. V1 said I didn't see him with anything in his hands. V1 said the male CNA was still in the room when she entered. V1 said R1 was in bed sleeping and she woke up when R2 was in the room. V1 said one of the CNAs had said R1 was screaming ahh, someone is in my room. On 8/15/23 at 12:44PM V2, Social Services, said I don't know if R2 ever physically harmed any resident or staff in the facility. (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: 145629 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 08/22/2023 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)