Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prairie Manor Nrsg & Rehab Ctr during CMS and state inspections, most recent first.
Staff failed to consistently don gowns and gloves or perform hand hygiene as required when providing direct care to residents on enhanced barrier precautions, including those with wounds and indwelling devices. Multiple staff members entered rooms, provided care, and handled resident items without appropriate PPE or hand hygiene, and interviews revealed misinterpretation of EBP policy and lack of awareness of posted requirements.
A resident with a stage 4 pressure ulcer was found to have a low air loss mattress set at 400 pounds, significantly higher than their actual weight of 265.8 pounds. The wound care nurse did not know how to adjust the setting and acknowledged that the mattress should be checked daily. This failure to set the mattress correctly resulted in increased firmness and pressure on the resident's wound, contrary to facility policy and CMS guidelines.
A resident with Parkinson's disease and multiple mobility impairments experienced six falls over six months, with the facility repeatedly implementing the same fall interventions despite the resident continuing to fall in similar circumstances. Staff interviews and documentation showed a lack of individualized assessment and adjustment of interventions, contrary to facility policy, resulting in ineffective fall prevention.
A facility failed to monitor a high-risk resident for pressure ulcers, resulting in an unstageable sacral wound. Despite weekly skin assessments, staff were unaware of the wound until the resident's hospital transfer. The resident had multiple health conditions, increasing their risk for pressure ulcers, but the facility's prevention policy was not effectively implemented.
A long-term care facility failed to adequately supervise and implement fall interventions for residents at risk of falls, resulting in significant injuries. A resident with a history of falls was left unsupervised in the dining room and sustained a femur fracture. Another resident, assessed as high risk, fell in her room due to inadequate environmental safety measures, leading to a femur fracture. A third resident fell from her bed and sustained a clavicle fracture, with preventive measures only implemented post-fall.
The facility failed to monitor and record daily freezer and refrigerator temperatures, potentially affecting all 123 residents receiving food. On a specific day, temperatures were not recorded due to staff shortages, with the refrigerator found at 32F, outside the acceptable range. The facility's policy requires daily temperature recordings, which were not completed.
The facility failed to document hospice services in the medical records of two residents, affecting coordinated care. One resident's hospice binder was empty, and another's was missing IDT progress notes. Staff interviews revealed confusion over documentation responsibilities, with hospice social service staff not recording visits and medical records staff not updating binders. Both residents were admitted to hospice care due to declining health, but the facility did not meet its policy and agreement requirements for documentation.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to follow its enhanced barrier precautions (EBP) policy and did not ensure staff consistently donned appropriate personal protective equipment (PPE) or performed hand hygiene as required during direct resident care. Certified nurse aides (CNAs) and nursing staff were observed entering rooms of residents on EBP without donning gowns, handling resident items, and providing care such as incontinence care and wound care without following PPE protocols. Staff were also seen exiting resident rooms and handling equipment or soiled linen carts before performing hand hygiene, contrary to facility policy and posted signage. Several residents were affected by these lapses. One CNA entered a resident's EBP room, rearranged personal items, and handled the resident's water pitcher without donning a gown or performing hand hygiene before leaving the room. Another CNA provided incontinence care to a resident on EBP without a gown and failed to perform hand hygiene before exiting the room and handling soiled linens. A wound care nurse provided wound care to a resident with a pressure ulcer requiring a dressing without donning a gown, despite facility signage indicating that any skin care requiring a dressing necessitates EBP. Additionally, a nurse provided colostomy care to a resident on EBP without donning a gown. Interviews with staff revealed confusion and misinterpretation of the EBP policy, with some staff believing that EBP should only be implemented for wounds present for 90 days or more, despite facility policy and CMS guidance indicating that EBP applies to any resident with wounds or indwelling medical devices. The infection prevention nurse was unaware of the specific requirements posted on EBP signage, and staff acknowledged that hand hygiene should be performed before exiting any resident room, which was not consistently done. Medical records confirmed the presence of wounds requiring dressings in affected residents, further supporting the need for EBP.
Incorrect Low Air Loss Mattress Setting for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set to the correct weight for a resident with a stage 4 pressure ulcer who required extensive assistance with turning and repositioning. During wound care observation, the wound care nurse was found to be unaware of how to adjust or unlock the mattress weight setting, which was locked at 400 pounds, despite the resident's actual weight being 265.8 pounds as documented in the medical record. The nurse acknowledged that the mattress setting should be checked daily and that an incorrect setting could result in increased pressure on the resident's wound. The resident in question had a significant medical history, including a stage 4 pressure ulcer extending from the left buttock to the sacrum and right buttock, requiring maximum staff assistance for bed mobility, toileting, and transfers. Facility policy and CMS guidance emphasize the importance of proper tissue load management and appropriate use of pressure-reducing support surfaces. The failure to adjust the mattress to the resident's actual weight resulted in the mattress being more firm than necessary, potentially increasing pressure on the wound area.
Failure to Implement Effective Fall Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement effective fall interventions tailored to the root cause for a resident with multiple falls. The resident, who had diagnoses including Parkinson's disease, functional quadriplegia, difficulty in walking, and orthostatic hypotension, experienced six falls over a six-month period. Despite being identified as a high fall risk, the interventions added after each fall were largely repetitive and did not address the underlying causes of the falls, such as the resident's attempts to self-transfer or refusal to use the call light for assistance. Documentation revealed that after each fall, interventions such as encouraging the use of the call light, keeping the environment safe, and providing education were repeated, even though the resident continued to fall in similar circumstances. There was no evidence of new or different interventions being implemented after repeated falls of the same nature. Staff interviews confirmed that interventions were often repeated, and there was a lack of clarity among staff regarding how fall interventions were chosen or evaluated for effectiveness. Some staff were unable to recall what interventions were put in place after specific falls, and there was no documentation of reassessment or modification of interventions when falls recurred. The facility's policy required that interventions be individualized and adjusted if falls recurred, and that staff monitor and document the effectiveness of interventions. However, the report shows that the same interventions were used multiple times without documented assessment of their effectiveness or consideration of alternative strategies. The resident's continued decline and repeated falls, despite these interventions, indicate that the facility did not adequately address the root causes of the falls as required by their own policy.
Failure to Monitor High-Risk Resident for Pressure Ulcers
Penalty
Summary
The facility failed to adequately assess and monitor a resident at high risk for pressure ulcers, leading to a deficiency in their Pressure Ulcer Prevention Program. The resident, who was initially admitted with multiple health conditions including CVA with left hemiparesis and protein calorie malnutrition, was transferred to the hospital due to a change in condition and returned with an unstageable wound on the sacral area. Despite the resident's high risk for pressure ulcers, the facility's staff, including the Wound Care Nurse and Director of Nursing, were unaware of the sacral wound prior to the hospital transfer. Weekly skin assessments were reportedly conducted, but the sacral wound was not identified until after the hospital visit. The report highlights that the facility's policy on pressure ulcer prevention was not effectively implemented, as evidenced by the lack of awareness and documentation of the resident's sacral wound. The Nurse Practitioner expressed that residents at high risk for pressure ulcers should have more frequent skin assessments than the weekly checks that were being performed. The facility's failure to conduct comprehensive skin assessments and document findings contributed to the oversight of the resident's condition, resulting in the development of an unstageable pressure ulcer.
Inadequate Supervision and Fall Prevention in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and implement fall interventions for residents at risk of falls, leading to significant injuries. Resident R1, who had a history of falls and was admitted for rehabilitation, fell in the dining room and sustained a right femur fracture requiring surgery. Despite being assessed as needing fall precautions, R1's baseline care plan lacked specific interventions for supervision or fall prevention. On the day of the fall, R1 was left unsupervised in the dining room after being wheeled there by a family member, and staff were not present to prevent the fall. Resident R2, who had a history of falls and was assessed as high risk, fell in her room and sustained a left femur fracture. The fall occurred while R2 was attempting to walk to the bathroom, despite being dependent on staff for all ADL care. Observations revealed that R2's bed was not consistently kept in a low position, and her call light was not always within reach, contrary to her care plan's interventions. These lapses in maintaining a safe environment contributed to R2's fall and subsequent injury. Resident R3, also at high risk for falls, fell from her bed and sustained a right distal clavicle fracture. R3 required substantial assistance for most ADLs and supervision for ambulation, yet was found on the floor with injuries. The care plan for R3 included interventions such as a low bed position and floor mats, but these were only implemented after the fall. The lack of consistent supervision and failure to implement preventive measures contributed to R3's fall and injury.
Failure to Monitor and Record Refrigerator and Freezer Temperatures
Penalty
Summary
The facility failed to monitor and record daily freezer and refrigerator temperatures for food safety, potentially affecting all 123 residents receiving food from the facility. On a specific day, the temperatures were not recorded due to staff shortages, as confirmed by the Dietary Manager. The observed temperatures were -3F for the freezer and 32F for the refrigerator, with the latter being outside the acceptable range according to the facility's policy. The facility's policy requires that refrigerators maintain temperatures between 36F and 41F, and freezers between -10F and 0F. The policy also mandates that a designated food service employee record the temperatures daily, with oversight by the food service supervisor. However, on the day in question, no temperature recordings were made, and the refrigerator was found to be at 32F, which is below the acceptable range. This oversight was communicated to the facility's administration and the President of Culinary Services.
Failure to Document Hospice Services in Resident Records
Penalty
Summary
The facility failed to ensure coordinated care for residents receiving hospice services by not documenting hospice services in the residents' medical records, which are supposed to be accessible to the interdisciplinary team (IDT). This deficiency affected two residents, R22 and R45, out of a sample of 25 reviewed for hospice care management. During the survey, it was observed that R22's hospice binder was empty, containing only a visit log from 6/12/24 to 7/4/24, with no IDT progress notes. Similarly, R45's hospice binder had missing IDT progress notes, with only a visit log from 6/10/24 to 7/9/24. Interviews with staff revealed a lack of clarity and responsibility regarding the documentation process, with the hospice social service staff not documenting visits and the medical records staff not updating the hospice binders regularly. R22 was admitted with a history of malignant neoplasm of the breast, chronic obstructive pulmonary disease, vascular dementia with psychotic disturbance, and other conditions, and was admitted to hospice care on 4/24/24 due to an overall decline in health. R45 was admitted with Alzheimer's disease, dementia with behavioral disturbance, oral phase dysphagia, acute kidney disease, and peripheral vascular disease, and was admitted to hospice care on 1/10/24 for similar reasons. The facility's policy requires all hospice service staff to document progress notes for each resident visit, and the hospice provider agreement mandates communication and documentation of services provided. However, these requirements were not met, leading to the deficiency noted by the surveyors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,405 citations issued within 25 miles in the last 12 months — including the 14 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ryze At Homewood | 1.6 mi | ★★★★★ | 13 | 1 |
| Aperion Care Chicago Heights | 1.7 mi | ★★★★★ | 12 | 0 |
| Bria Of Chicago Heights | 2.4 mi | ★★★★★ | 2 | 0 |
| Aliya Of Homewood | 3 mi | ★★★★★ | 3 | 0 |
| Aliya Of Glenwood | 3.1 mi | ★★★★★ | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.