Prairie Manor Nrsg & Rehab Ctr

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

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 (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 Resident R2's sacral pressure ulcer. Resident 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 Resident 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 Resident R2 does not weigh 400 pounds but would have to check Resident R2's medical record to know what Resident 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. Resident R2's medical record, dated 12/4/25, notes Resident R2's weight was 265.8 pounds. Resident R2's wound assessment details report, dated 12/15/25, notes Resident 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. Resident R2's MDS (minimum data set), dated 11/7/25, notes Resident R2 requires maximum assistance from staff with bed mobility. Resident 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.

Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

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:

If continuation sheet