Health inspection·April 6, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to transcribe and follow physician orders for wound treatment of a surgical wound for 5 days, and failed to notify the resident representative of the treatment plan to leave sutures in place beyond the usual time frame, for 1 of 1 resident (R2) reviewed for physician orders and notification. Residents Affected - Few Findings include: On 3/31/23 at 10:44AM, V18 (R2's family) said the facility left R2 sutures in longer than they were supposed to, and the sutures were supposed to only stay in for 10 days. V18 said R2 got sutures on 2/14/23 after sustaining a laceration to the right leg when she was being transferred to bed. R2's face sheet shows R2 has diagnosis of pain in left shoulder, pain left knee, atherosclerotic heart disease, heredity and idiopathic neuropathy, obesity, bilateral artificial knee, urinary tract infection, other abnormalities of gait and mobility, other reduced mobility, abnormal posture, history of falling. R2's face sheet denotes R2 has a power of attorney for care. R2 MDS (Minimum Data Set), dated 1/4/23, denotes, in-part, R2's BIMs score of 11 (mild cognitive impairment). On 4/4/23 at 10:27AM, V11 (wound treatment nurse) said R2 sustained a laceration to the right leg during a wheelchair to bed transfer. V11 said R2 saw the wound doctor on 3/1/23, and the wound treatments to the right leg was changed on 3/1/23. V11 said the orders were not initiated until 3/6/23. V11 said the orders were changed to Bactroban and calcium alginate. V11 said Bactroban is an antimicrobial that treats and prevents infections, and calcium alginate is used as an absorbent with there is exudate from the wound. V11 said physician orders should be implemented immediately when ordered. V11 said initiating the wound treatment on 3/6/23, five days after the physician order, was not appropriate when following physician orders. V11 (wound treatment nurse) said the plan was to keep R2's sutures in place longer than usual. V11 said the physician removed several sutures from R2's right leg wound, and the plan was to keep the 3 sutures in place so that the wound would not fail (open). V11 said she did not discuss this with the family, she only informed the family that the wound was stable. V11 said a care plan was not developed for the sutures, there was a plan of care for the right leg wound. Review of R2's wound care assessment and progress note, dated 3/1/23, denotes, in-part, exam, reviewed patients' chart, discussed prognosis and tx (treatment) options with nursing staff and patient, removed all non-productive sutures today, leaving distal 3 present for removal next week. Dressed RLE (right lower extremity) wound with Bactroban, adaptic, calcium alginate and foam island, continue 3x/wk (week) after 0.9% NS( normal saline) and cover with tubi grip and derma saver. Dressed LLE (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: 145382 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 145382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lee Manor 1301 Lee Street Des Plaines, IL 60018 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)