Health inspection·July 12, 2024

F 0812 any cross contamination and food born illnesses. Level of Harm - Minimal harm or potential for actual harm Process: Residents Affected - Many 6. All readily perishable foods or beverages shall be maintained at temperatures of 7 degrees C (41 degrees F or below or at 60 degrees C (140 degrees F) or above, at all times, except for very short times during necessary periods of preparation or service. 7. Frozen foods shall be stored at minus) degrees or below at all times. (There is an accurate thermometer in each refrigerator and freezer) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145629 If continuation sheet Page 2 of 4 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 07/12/2024 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 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure coordinated care was implemented by failure to document hospice services rendered to resident's medical record that is available and accessible to interdisciplinary team (IDT). This deficiency affects two (R22 and R45) of three residents in the sample of 25 reviewed for Hospice care Management. Findings include: On 7/9/2024 at 11:00AM, V8 LPN (Licensed Practical Nurse) and V9 LPN said that R22 and R45 are both on hospice care. V9 showed the hospice binder/charts for both residents. Reviewed both hospice binder charts with V9. Noted no documents found for R22. The folder is empty, only visits log from 6/12/24 to 7/4/24. No IDT progress notes found. Noted R45 hospice documents in binder but missing IDT progress notes. Noted R45's hospice visit log from 6/10/24 to 7/9/24. V9 said usually when hospice care staff comes to visit hospice resident, they document in the hospice binder. V9 said that usually Social Services coordinate with hospice care management. On 7/9/24 at 11:33AM, V10 Social Service said that she is only responsible for referral to hospice vendors/services, the Social Service Director is the one responsible for making sure all hospice documents for coordinated care are in the hospice binder. On 7/9/24 at 11:48AM, V11 Hospice Social Service (HSS) said that he comes to see both R22 and R45. He said that the last time she visited both was last month but cannot remember the date. He said he did not log in and did not document his visit and services provided last month. He said that he cannot find the hospice binder and he cannot find a nurse from the unit to ask. He added that only the hospice nurses are required to document, he is social service, and he does not need to document in the hospice progress notes. V9 LPN overheard what V11 HSS told the surveyor, and she denied that there is no nurse available in the unit. V9 said that the binder is placed in the nursing station desk and there are always staff available in the unit if he needs assistance. On 7/9/24 at 11:53AM, V6 Medical Record said that she is responsible to make sure all hospice coordinated care documents are in place and updated in the hospice binder. She should be monitoring it weekly and uploading it in resident electronic chart. She said that she has not been doing it for a while. Reviewed R22 and R45 hospice records with V6. Noted no hospice documents/assessments/IDT progress notes in R22's folder. R45 does not have IDT progress notes, last progress notes dated 6/12/24 done by RN. On 7/11/24 at 10:00AM, Reviewed R22's hospice medical records with V9 LPN and noted that all documents were faxed by hospice provider dated 7/9/24 after the surveyor found out that there are no hospice documents in chart. R22 was admitted on [DATE] with diagnosis listed in part but not limited to History of Malignant neoplasm of breast, Chronic obstructive pulmonary disease, Vascular dementia with psychotic disturbance, history of transient ischemic attack and cerebral infarction. Active physician order sheet indicates she was admitted to hospice care on 4/24/24. Care plan indicates that she is admitted to hospice care due to overall decline in health. Hospice binder does not have hospice record documents except for IDT visit log from 6/12/24 to 7/4/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145629 If continuation sheet Page 3 of 4 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 07/12/2024 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 0849 Level of Harm - Minimal harm or potential for actual harm R45 was admitted on [DATE] with diagnosis listed in part but not limited to Alzheimer's disease, Dementia with behavioral disturbance, Oral phase dysphagia, Acute Kidney disease, Peripheral vascular disease. Active physician order sheet indicates she was admitted to hospice care on 1/10/24. Care plan indicates that she is admitted to hospice care due to overall decline in health. Hospice binder does not have IDT progress notes documentation except for visit log dated from 6/10/24 to 7/9/24. Residents Affected - Few Facility's policy on Hospice services indicates: Policy: It is the policy of this facility 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 of their lives. The facility will provide hospice services either directly or through arrangements with a qualified service provider. Standards: 6. All hospice service staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available in the medical record for all interdisciplinary staff to access. Hospice provider single patient agreement for residential hospice services provided in the nursing facility for R22 and R45 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 or at each hospice patient visit to ensure that the needs of each hospice patient are addressed and met 24 hours per day. 11. Clinical Record.Each clinical record shall completely, promptly, and accurately document all services provided to and events concerning, the hospice patient (including . progress notes) as required by this agreement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145629 If continuation sheet Page 4 of 4