Prairie Manor Nrsg & Rehab Ctr
PRAIRIE MANOR NRSG & REHAB CTR in CHICAGO HEIGHTS, IL — inspection on December 23, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observations, interviews, and record reviews, the facility failed to have the low air loss mattress at the correct weight setting for one resident (R2) with a stage 4 pressure ulcer, who is at risk for skin breakdown and requires extensive assistance with turning/repositioning, out of three residents reviewed for wound management in a sample of 6.
Findings include:On 12/19/25 at 8:55 AM, this surveyor observed V3 (wound care nurse) provide wound care treatment for R2's sacral pressure ulcer. R2 was observed to have a low air loss mattress with the weight setting at 400 pounds. On 12/19/25 at 9:05 AM, V3 stated that the weight on R2's low air loss mattress is locked and V3 does not know how to unlock it to adjust the weight setting. V3 stated that the machine is set for a person weighing 400 pounds. V3 stated that she knows R2 does not weigh 400 pounds but would have to check R2's medical record to know what R2's current weight is. V3 stated that the weight setting on the mattress should be checked daily. V3 stated that she will have to ask maintenance to come fix the weight setting. V3 stated that the resident's weight determines how much air flows through the mattress. V3 stated that the specialty mattress would be more firm if the weight setting was set higher than the resident's actual weight causing more pressure on the resident's wound. V3 stated that you don't want too much pressure on wound d/t increased setting of weight. R2's medical record, dated 12/4/25, notes R2's weight was 265.8 pounds. R2's wound assessment details report, dated 12/15/25, notes R2 with a stage 4 pressure ulcer left buttock to sacrum to right buttock.
Wound was identified on 5/7/24.
Wound measures 5.5cm (centimeters) x 4cm x 1cm. R2's MDS (minimum data set), dated 11/7/25, notes R2 requires maximum assistance from staff with bed mobility. R2 is dependent on staff for toileting and transfers.
The facility's pressure wound treatment policy, dated 01/2017, notes, in part, the pressure injury treatment program should focus on tissue load.
Tissue load refers to the pressure, tension, and mechanical forces on injured skin and underlying tissues. CMS (Centers for Medicare & Medicaid Services) article titled pressure reducing support surfaces - group 2 policy article, dated 4/7/22, notes, in part, that styles of group 2 powered pressure reducing mattresses (alternating pressure, low air loss) which is characterized by all of the following: an air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress, inflated cell height of the air cells through which air is being circulated is 3.5 inches or greater, height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent bottoming out, ands a surface designed to reduce friction and shear, and can be placed directly on a hospital bed frame.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairie Manor Nrsg & Rehab Ctr
345 Dixie Highway Chicago Heights, IL 60411
SUMMARY STATEMENT OF DEFICIENCIES
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.
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