Health inspection·February 14, 2025

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 assess and monitor for pressure ulcers for a resident who is at high risk for pressure ulcers. This deficiency affects one (R2) of three residents reviewed for Pressure Ulcer Prevention Program. Residents Affected - Few Findings include: On 2/13/25 at 11:25 AM, V4 (Wound Care Nurse) said that R2 was sent to the hospital on 1/24/25 for change in condition, R2 was observed unresponsive and abnormal vital signs. V4 said R2 only had scar tissue to the sacral area but no open skin. When R2 returned to the facility on 1/31/25, R2 returned with an unstageable wound that the hospital did debridement. V4 said that R2's son and husband were made aware of resident change of condition and hospital transfer. V4 said that R2's wound care is done weekly, and measurements are also done on a weekly basis and weekly wound rounds with MD. On 2/13/25 at 1:45PM, V2 (Director of Nursing) said that weekly skin assessments are completed during wound care treatments and are documented on shower sheets. V2 said she was unaware of R2 having a sacral wound, no staff verbalized any concerns for R2. On 2/13/25 at 1:45 PM, V11(Licensed Practical Nurse) said she was the nurse that sent R2 to the hospital at the start of her evening shift. R2 was observed with a change in condition, not her normal self. V11 notified Nurse practitioner and obtained orders to transfer to hospital. V11 said that she did wound treatment to bilateral lower extremities, but did not do a full body assessment before R2 left to hospital. V11 notified R2's son and husband of transfer. V11 said that skin assessments are done weekly and also when she has a shower a skin assessment is done and documented on the shower sheets. On 2/14/24 at 12:27 PM, V16 (Nurse Practitioner) said that on 1/24/25 when R2 was transferred to the hospital she was unaware of any wounds to the sacral area. R2 had multiple wounds on her legs, but not sacral area, V16 said that her expectations of the facility generally should be doing skin assessments on residents that are high at risk for developing ulcers more frequently than weekly skin assessments. R2 was initially admitted on [DATE] and was re-admitted on [DATE] with diagnosis listed in part but not limited to: CVA with left hemiparesis, Cognitive Communication deficit, muscle weakness with atrophy, PVD, epilepsy, dysphagia, metabolic encephalopathy, GERD, pulmonary nodule, anemia, T2DM, protein calorie malnutrition, Vit D deficiency, hyperlipidemia, hypertension, CKD, Encounter for change or removal of surgical wound dressing. admission and current Braden/skin assessment indicated that she is at high risk for developing pressure ulcers/skin impairments. Active physician order sheet (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 2 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 02/14/2025 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)