Health inspection·December 23, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to follow its enhanced barrier precautions (EBP) policy and don appropriate PPE (personal protective equipment) prior to entering an EBP resident room to provide direct resident care and failed to perform hand hygiene before exiting a resident's room after providing direct resident care. These failures affected four residents (R2, R3, R4, and R5) out of five residents reviewed for infection control in a sample of 6. Findings include: On 12/18/25 at 11:04 AM, V10 CNA (certified nurse aide) was observed entering R3's EBP room and rearranging R3's personal items on bedside table. V10 then exited R3's room with R3's water pitcher and placed it on the counter at the nurses' station. V10 was then observed placing the mechanical lift device in the tub room and return to the nurses' station to wash hands. V10 then filled R3's water pitcher and brought into R3's room. On 12/18/25 at 11:25 AM, V6 CNA entered R2's EBP room to provide incontinence care. V6 did not don a gown prior to entering R2's room. At 11:31 AM, V6 exited R2's room, removed gloves, went to the tub room, opened the door and grabbed a soiled linen rolling cart. V6 brought cart to R2's room and placed soiled linen in cart then brought cart to tub room. V6 did not perform hand hygiene prior to exiting R2's room. V6 was then observed washing hands at sink in nurses' station. On 12/19/25 at 8:20 AM, this surveyor observed V4 (wound care nurse) enter R5's room to provide wound care treatment for R5's right buttock wound. The signage on R5's door notes EBP - wound care - any skin care requiring a dressing. V4 did not don a gown prior to entering R5's room. On 12/19/25 at 8:30 AM, V3 (wound care nurse) stated that R5 is not on enhanced barrier precautions; his roommate, R4, is due to having a colostomy. When questioned if R5 has a wound that requires a dressing, V3 responded yes but he is not on EBP. V3 stated that the facility interpreted the EBP policy to refer to chronic wounds. V3 stated that a resident's wound must be present for 90 days before the resident is placed on enhanced barrier precautions. On 12/19/25 at 10:20 AM, V9 LPN (licensed practical nurse) was observed providing colostomy care to R4. R4 is on EBP. V9 did not don a gown prior to preforming direct resident care. On 12/19/25 at 1:20 PM, V5 (infection prevention nurse) stated that if resident has a wound for 90 days, then we will place the resident on enhanced barrier precautions. V5 stated that this is the facility's EBP policy. V5 stated that she is not aware that the facility's EBP signage notes: wound care -- any skin care requiring a dressing. V5 stated that each resident room has a hand sanitizing dispenser, and a bathroom sink for staff to wash hands. V5 stated that staff are expected to perform hand hygiene prior to exiting any resident's room. V5 stated that staff should not exit the resident's room, go to tub room to grab a cart or return equipment, then perform hand hygiene at the nurses' station. R5's medical record notes R5 with a right buttock pressure ulcer identified on 11/3/25. Wound measures 3.6cm (centimeters) x 3.2cm x 0.1cm.R5 with diagnoses of chronic obstructive pulmonary disease, severe protein-calorie malnutrition, prostate cancer, adult failure to thrive, cancer of kidney, secondary cancer of other parts of the nervous system. These factors may delay or prevent wound healing and may put R5 at risk for further breakdown. On 11/24/25, R5's right buttock wound measured 2.2cm x 1.7cm x 0.1cm. On 12/1/25, V3 noted R5's Left buttock MASD (moisture associated skin damage) area and right buttock wound area have conjoined. On 12/15/25, R5's right buttock pressure ulcermeasured 3.6cm x 3.2cm x 0.1cm. R5's POS, dated 11/4/25, notes wound care: right buttock: cleanse with normal saline, pat dry, apply hydrogel to wound bed, secure with border gauze/dry dressing daily and as needed if soiled or dislodged.The facility's enhanced barrier precautions signage notes everyone must: clean their hands, including before entering and when leavingthe room. Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities. Dressing,bathing, changing linens, providing hygiene, changing briefs or assisting with Residents Affected - Some (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 12/23/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete toileting, device care or use, wound care: any skin openingrequiring a dressing. The facility's enhanced barrier precautions policy, revised 3/21/24, notes, in part, enhanced barrier precautions refer to the use of gownand gloves for use during high-contact resident care activities for residents at increased risk of multidrug resistant organism acquisition (residents with wounds). Initiation of enhanced barrier precautions - implement enhanced barrier precautions for residents with any of the following: wounds. High-contact resident care activities include: dressing, bathing, transferring, providinghygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care: any skin opening requiring a dressing. On 12/19/25, V1 (administrator) presented the CMS (Centers for Medicare & Medicaid Services) memorandum, dated 3/20/24, enhanced barrier precautions in nursing homes. This guidance notes enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing. Event ID: Facility ID: 145629 If continuation sheet Page 3 of 3