Health inspection·April 26, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attending and participating in activities of choice (3 times weekly) by next review date; That goal was given when she first came into the building and does not match her capabilities in general; She isn't able to participate in group due cognitive decline and needs total assist in all activities of daily living; she will remain in the dining area and will listen to music and observe while holding props for texture; her husband is also very much involve and if weather is nice he takes her for a stroll outside; her new goal includes being included in the large group and observing group while listening to music when not outside with her husband through next review date. R13's Activities Progress note, dated 3/24/2023, documents her last goal was to be included in the large group while listening to the music when not outside with her husband throughout next review date; she remains in the dining area and listens to music and activity assistant provides hand massage at least once a week; her husband visits twice daily in the morning for breakfast and in the evening for dinner and he spends quality time with her; her husband usually talks to her or feeds her goodies that he brings for her; she is unable to express herself verbally; her new goal includes listening to the music on a daily basis while also getting a gentle hand massage throughout next review date. 2. On 04/24/23 at 10:50 AM, R118 was in the dining area during activities, sitting in his wheelchair at a table alone, with no activity materials for several minutes, while multiple other residents were provided coloring materials and bead mazes. R118 answered yes when the surveyor asked him if he wanted to color. When asked if R118 was offered coloring materials, V17 (Activities Director) stated she will offer them to him now. R118 accepted V17's offer to color. R118 colored with no issue with V17's assistance. Music playing from the television in the dining area during activities. On 04/25/23 from 10:40 AM - 10:57 AM, R118 was in the dining area during activities, sitting in his wheelchair at a table alone, not being engaged by activities staff, and without any activity materials, while several other residents were participating in activities with staff directly across from R118. Observed no staff attempt to engage R118 in activities during this time. Observed music playing from the television in the dining area during activities. R118's current care plan, initiated 01/27/2023, documents he is no longer able to watch and, we don't know if he is even listening to anything that goes around him. R118 is in the dining area around others, he only watches people but is unable to do anything at this point he will only accept hand massage and activities staff will play music for him; interventions also include play music for R118 on a daily basis; provide hand massage once a week or as tolerated. R118's current care plan does not include information about his interests or personalized interventions based on his past interests or hobbies. R118's admission Activities Assessment, dated 09/17/2019, documents he has some ability to participate in activities; his recreational interests include newspaper sports edition, dogs, spring gardening, sports, watching action/comedy movies, fresh air, always liked to stay active, and votes; his favorite summer activities included planning summer vacation with family, his favorite fall activities included preparing to decorate for Halloween, his favorite winter activities included getting ready for the holidays; he needs encouragement, prefers a small group; during activities he does prefer to spend time observing, and participates in activities of his interest; A lot of encouragement is needed in order to receive participation from resident. R118's Quarterly Activities Assessment, dated 10/28/2022, references progress notes for details; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 2 of 11 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 04/26/2023 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and notes his advanced dementia limits his ability to independently choose activities and he requires total assistance to wheel to and from activities. R118's Quarterly Activities Progress note, dated 10/28/2022, documents his last goal included watching television, listening to music and accepting daily news in room through next review date; he is unable to participate in any group activity due to cognitive deficit and physical capability; he is also unable to speak and can't verbalize needs and wants, therefore staff will keep him dry and comfortable every shift; he will continue to listen to music and will hold props for sensory stimuli; his daughters visit resident often and they always bring goodies and clothes for him; his new goal includes watching television, listening to music and accepting daily news in his room through next review date. R118's Quarterly Activities Progress note, dated 4/25/2023, documents his last goal included continuing to bring him to the dining area on a daily basis and activities staff will continue to play music while providing hand massage once a week; R118 is in the dining area for the most part and is unable to participate in the active games and is also unable to follow directions; for the most part we play music for him and provide a hand massage once a week as well as coffee and cookies and assistance with feeding him the cookie; daughter visits monthly and they bring food and favorite drink for him; we will continue with goal and approach. On 04/26/23 from 12:51 PM - 1:40 PM, V25 (MDS Coordinator/Psychotropic Nurse/RN) stated from her observation, R13 has not been engaging even with V26 (Family Member) who visits twice daily, and does not have that much interaction. V25 stated there have been some sporadic episodes where R13 talks or interacts a little, but are very rare. V25 stated V17 (Activities Director) would be responsible for preparing the activities care plan. V17 stated R13 is not interactive. V17 stated she did not review R13's records from when she was located on another floor when completing her activities assessment, but she could speak with V26 to create a more personalized care plan for her. V17 stated she has asked V26 about R13's prior interest, and he informed that she never really participated in activities, and her main interests are family and family reunions and family oriented activities. V17 stated R13's and R118's activities care plans should be more personalized. V17 stated she is in the middle of training activities staff and has begun initiating a small group for residents like R13 and R118 who have lower functioning residents. The facility's Care Plans, Comprehensive Person Centered Policy reviewed 04/25/23 states: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's psychosocial needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care planning process will: facilitate resident and/or representative involvement; include an assessment of the resident's strengths and needs; and incorporate the resident's personal and cultural preferences in developing the goals of care. The comprehensive, person-centered care plan will: include measurable objectives; describe the services that are to be furnished to attain or maintain the resident's highest practicable mental and psychosocial well-being; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 3 of 11 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 04/26/2023 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)

F 0656 The facility's Activity Programs Policy states: Level of Harm - Minimal harm or potential for actual harm Activity programs are designed to meet the interests of and support the mental and psychosocial well-being of each resident. Residents Affected - Few Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. The activities program is ongoing and includes independent individual activities and assisted individual activities. (Activities) are considered any endeavor, other than routine Activities of Daily Living, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance cognitive or emotional health. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Individualized activities are provided that: reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 4 of 11 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 04/26/2023 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)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personalized activities were provided for vulnerable residents based on their interests, preferences and needs. This failure applied to two (R13 and R118) of 35 residents reviewed for activities. Residents Affected - Few Findings include: 1. On 04/24/23 from 10:46 AM - 11:10 AM, R13 was in the dining area during activities, sitting in her wheelchair at a table alone, with a puzzle [NAME] sitting on the table in front of her. Observed no staff attempt to assist R13 with the puzzle [NAME] or engage her during this time. Observed music playing from the television in the dining area during activities. On 04/25/23 from 10:40 AM - 10:57 AM, R13 was in the dining area during activities, sitting in her wheelchair at a table alone with a puzzle [NAME] sitting on the table in front of her while several other residents were participating in activities with staff directly across from R13. Observed no staff attempt to assist R13 with the puzzle [NAME] or engage her in activities during this time. Observed music playing from the television in the dining area during activities. R13's current care plan, initiated 03/24/2023,, documents she is dependent on staff for all activities of daily living, she is unable to express herself and unable to get to and from activities room, husband comes twice daily to visit and assist her to eat, she will continue in the dining area and will listen to music and accept hand massage as needed; interventions also include invite and escort resident to all group activities. R13's care plan does not include information about her interests or personalized interventions based on her past interests or hobbies. R13's admission Activities Assessment, dated 06/23/2022, documents she was born in Italy, is of Catholic religion, is not interested in puzzles or music, an interview for daily and activity preferences can be conducted, prefers large or small groups, she was formerly a business owner; she was new to the facility and needs a lot of encouragement and assistance due to dementia; she has a private caregiver; activities aides will provide pop and friendly visits daily for socialization; goals include attending/participating in activities of choice (3 times weekly) by next review date; R13's past hobbies and interests were not included in the assessment. R13's Quarterly Activities Assessment, dated 10/28/2022, references progress notes for details and notes she is dependent of staff to participate in activities due to dementia. R13's Quarterly Activities Progress note, dated 10/28/2022, documents her last goal included attending and participating in activities of choice (3 times weekly) by next review date; That goal was given when she first came into the building and does not match her capabilities in general; She isn't able to participate in group due cognitive decline and needs total assist in all activities of daily living; she will remain in the dining area and will listen to music and observe while holding props for texture; her husband is also very much involve and if weather is nice he takes her for a stroll outside; her new goal includes being included in the large group and observing group while listening to music when not outside with her husband through next review date. R13's Activities Progress note, dated 3/24/2023, documents her last goal was to be included in the large group while listening to the music when not outside with her husband throughout next review (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 5 of 11 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 04/26/2023 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)

F 0679 Level of Harm - Minimal harm or potential for actual harm date; she remains in the dining area and listens to music and activity assistant provides hand massage at least once a week; her husband visits twice daily in the morning for breakfast and in the evening for dinner and he spends quality time with her; her husband usually talks to her or feeds her goodies that he brings for her; she is unable to express herself verbally; her new goal includes listening to the music on a daily basis while also getting a gentle hand massage throughout next review date. Residents Affected - Few 2. On 04/24/23 at 10:50 AM, R118 was in the dining area during activities, sitting in his wheelchair at a table alone, with no activity materials for several minutes, while multiple other residents were provided coloring materials and bead mazes. R118 answered yes when the surveyor asked him if he wanted to color. When asked if R118 was offered coloring materials, V17 (Activities Director) stated she will offer them to him now. R118 accepted V17's offer to color. R118 colored with no issue with V17's assistance. Observed music playing from the television in the dining area during activities. On 04/25/23 from 10:40 AM - 10:57 AM, R118 was in the dining area during activities, sitting in his wheelchair at a table alone, not being engaged by activities staff and without any activity materials while several other residents were participating in activities with staff directly across from R118. No staff attempted to engage R118 in activities during this time. Observed music playing from the television in the dining area during activities. R118's current care plan, initiated 01/27/2023, documents he is no longer able to watch and, we don't know if he is even listening to anything that goes around him. R118 is in the dining area around others, he only watches people but is unable to do anything at this point he will only accept hand massage and activities staff will play music for him; interventions also include play music for R118 on a daily basis; provide hand massage once a week or as tolerated. R118's current care plan does not include information about his interests or personalized interventions based on his past interests or hobbies. R118's admission Activities Assessment, dated 09/17/2019, documents he has some ability to participate in activities; his recreational interests include newspaper sports edition, dogs, spring gardening, sports, watching action/comedy movies, fresh air, always liked to stay active, and votes; his favorite summer activities included planning summer vacation with family, his favorite fall activities included preparing to decorate for Halloween, his favorite winter activities included getting ready for the holidays; he needs encouragement, prefers a small group; during activities he does prefer to spend time observing, and participates in activities of his interest; A lot of encouragement is needed in order to receive participation from resident. R118's Quarterly Activities Assessment, dated 10/28/2022, references progress notes for details; and notes his advanced dementia limits his ability to independently choose activities and he requires total assistance to wheel to and from activities. R118's Quarterly Activities Progress note, dated 10/28/2022, documents his last goal included watching television, listening to music and accepting daily news in room through next review date; he is unable to participate in any group activity due to cognitive deficit and physical capability; he is also unable to speak and can't verbalize needs and wants, therefore staff will keep him dry and comfortable every shift; he will continue to listen to music and will hold props for sensory stimuli; his daughters visit resident often and they always bring goodies and clothes for him; his new goal includes watching television, listening to music and accepting daily news in his room through next (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 6 of 11 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 04/26/2023 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)

F 0679 review date. Level of Harm - Minimal harm or potential for actual harm R118's Quarterly Activities Progress note, dated 4/25/2023, documents his last goal included continuing to bring him to the dining area on a daily basis and activities staff will continue to play music while providing hand massage once a week; R118 is in the dining area for the most part and is unable to participate in the active games and is also unable to follow directions; for the most part we play music for him and provide a hand massage once a week as well as coffee and cookies and assistance with feeding him the cookie; daughter visits monthly and they bring food and favorite drink for him; we will continue with goal and approach. Residents Affected - Few On 04/26/23 from 12:51 PM - 1:40 PM, V25 (MDS Coordinator/Psychotropic Nurse/RN) stated from her observation R13 has not been engaging even with V26 (Family Member), who visits twice daily and does not have that much interaction. V25 stated there have been some sporadic episodes where R13 talks or interacts a little, but are very rare. V25 stated V17 (Activities Director) would be responsible for preparing the activities care plan. V17 stated R13 is not interactive. V17 stated she did not review R13's records from when she was located on another floor when completing her activities assessment, but she could speak with V26 to create a more personalized care plan for her. V17 stated she has asked V26 about R13's prior interest, and he informed that she never really participated in activities and her main interests are family and family reunions and family oriented activities. V17 stated R13's and R118's activities care plans should be more personalized. V17 stated she is in the middle of training activities staff and has begun initiating a small group for residents like R13 and R118 who have lower functioning residents. The facility's Care Plans, Comprehensive Person Centered Policy reviewed 04/25/23 states: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's psychosocial needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care planning process will: facilitate resident and/or representative involvement; include an assessment of the resident's strengths and needs; and incorporate the resident's personal and cultural preferences in developing the goals of care. The comprehensive, person-centered care plan will: include measurable objectives; describe the services that are to be furnished to attain or maintain the resident's highest practicable mental and psychosocial well-being; The facility's Activity Programs Policy states: Activity programs are designed to meet the interests of and support the mental and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. The activities program is ongoing and includes independent individual activities and assisted individual activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 7 of 11 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 04/26/2023 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)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (Activities) are considered any endeavor, other than routine Activities of Daily Living, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance cognitive or emotional health. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Individualized activities are provided that: reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 8 of 11 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 04/26/2023 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments every six months for monitoring of side effects while using antipsychotic medication for a resident who was exhibiting signs of sudden, irregular facial movements. This failure applied to one (R18) of five residents reviewed for unnecessary medications in sample of 35. Findings include: R18 is a [AGE] year-old female, with a Diagnoses History includes Alzheimer's, Recurrent Major Depressive Disorder (11/7/2016), Vascular Dementia, Unspecified Psychosis (as of 02/26/2010), Anxiety Disorder (12/27/2007), and Epilepsy who was admitted to the facility 12/01/2005. R18's current physician orders documents an active order effective 02/03/2021 for one 1mg Abilify (Antipsychotic) tablet to be given by mouth once daily related to unspecified Psychosis. R18's April 2023 Medication Administration Record documents she received Abilify daily as ordered from April 1 - 25th. R18's Pharmacist Clinical Review & Recommendations from January - April 2023 does not document any irregularities. R18's AIMS (Abnormal Involuntary Movement Scale), dated 09/16/2021, documents she exhibited minimal facial or oral movements including facial expressions and lip/mouth movements, and mild tongue movements with a final score of 5. R18's AIMS (Abnormal Involuntary Movement Scale), dated 12/07/22, documents she has not exhibited any signs of abnormal facial movements with a final score of 0. There were no other AIMS assessments located in R18's medical records from 09/16/2021 - 04/24/2023, and none provided by the facility during the survey from that time period. On 04/25/25 at 10:40 AM, R18 was smacking her lips, opening and closing her mouth, and thrusting her tongue repetitively. R18's dentures were moving in and out of her mouth. R18's Psychiatric Progress Note Report, dated 04/11/2023, documents she was personally examined by the Nurse Practitioner, was examined and reviewed for side effects and a brief neurological exam was completed to rule out Tardive dyskinesia (a condition where your face, body or both make sudden, irregular movements which you cannot control) with no abnormal movements noted; will titrate or make adjustments to dose of medications based on current symptom progression; no side effects noted, counseling provided on potential side effects, nursing staff advised to call with adverse side effects. On 04/25/23 from 11:46 AM - 12:00 PM, V2 (Director of Nursing) stated she noticed R18 has Tardive Dyskinesia (Abnormal Involuntary Movements) such as her movements with her eyes and sometimes involuntary facial movements. V2 stated R18 has been at the facility for approximately 10 years. V2 stated R18 is on psychotropic medication. V2 stated R18 has exhibited the facial movements for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 9 of 11 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 04/26/2023 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few approximately more than a year. V2 stated AIMS assessments are conducted every six months, and when there are any changes. On 04/26/23 from 12:51 PM - 1:40 PM, V25 (MDS Coordinator/Psychotropic Nurse/Registered Nurse) stated she is aware of R18's symptoms of Tardive Dyskinesia (TD), and has performed an AIMS assessment on her and observed her to have those symptoms as well. V25 stated she believes she observed R18 with these symptoms during the AIMS she conducted in September 2021. V25 stated she is not sure why an AIMS assessment was not conducted every six months for R18, but there were some challenges for completing assessments during COVID. V25 stated R18's signs and symptoms of TD are minimal, and may be on and off, and perhaps may have been unnoticeable during her December AIMS assessment. V25 stated there have been some dose reductions in R18's psychotropic medications from 2018 - current. V25 stated in July of 2018, R18 was taking Abilify at 5mg once daily, then in September of 2018 it was reduced to 2.5mg daily, in November of 2019 the Ability was lowered to 2mg once daily, then in February of 2021 the Abilify was reduced to 1mg daily. V25 stated R18's TD symptoms could potentially have not been present during the time of her December 2022 AIMS due to her dose reductions, but she cannot be certain of that. V25 stated she believes R18's TD symptoms have persisted since identified, and she has been on antipsychotics for a long time. V25 stated the AIMS assessments should be conducted every six months to ensure there is no worsening of R18's TD. The facility's Psychotropic Medication Policy and Procedure revised 07/29/2019 states: It is the policy of the facility that physicians/medical providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. AIMS (Abnormal Involuntary Movement Scale) will be performed on any resident on an antipsychotic on initiation of medication and every 6 months; significant change will be reported to the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 10 of 11 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 04/26/2023 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication administration error rate below 5%. There were 25 opportunities with two errors resulting in an 8% medication error rate observed. This failure applied to two (R83 and R177) of two residents reviewed during the medication administration task. Residents Affected - Few Findings include: 1. On 04/23/23 at 10:12 AM during medication pass observation, V16 (Registered Nurse, RN) was observed preparing R83's Diclofenac gel. R83's MAR (Medication Administration Record) recorded: Diclofenac Sodium External Gel 1% apply to neck area topically four times a day for pain on the neck area apply 2 grams (gms) 4 times a day. V16 squeezed the Diclofenac gel onto her finger and applied to R83's neck area. R83 stated, A little bit more. V16 squeezed more of the Diclofenac gel and spread it again onto her (R83) neck. V16 was asked regarding dose as ordered. V16 replied, I squeezed like a bunch on my finger, its already 2 gms. I should have used the dosing card but I cannot find it. According to Diclofenac Sodium topical Gel, 1% Instructions for Use: Important: Use the dosing card that is inside the Diclofenac Sodium topical gel carton to correctly measure each dose. The dosing card is re-usable. Do not throw the dosing card away. 2. On 04/23/23 at 10:30 AM, V16 was preparing R177's Polyethylene Glycol . R177's MAR documented: Polyethylene Glycol Powder (Polyethylene Glycol 1450) give 17 grams (g) by mouth one time a day. V16 poured the Polyethylene Glycol using the cap, filled the cap at the second line, which was below the top line. V16 verbalized, I used the cap and filled it until this line, not the top line. The back of the Polyethylene Glycol bottle stated in part: Directions in the back of the bottle: Adults and children [AGE] years of age and older: Fill to the top of the bottle cap which will provide the correct dose (17g). On 04/25/23 at 11:59 AM, V2 (Director of Nursing) was interviewed regarding medication administration. V2 replied, Staff needs to follow the 7R's during medication administration - right patient, right dose, right time, right route, right frequency, right medication/drug and right documentation. Nurses must follow the manufacturer's guidelines or specific instructions for medication administration. Facility's policy titled, Administering Medications, revised date April 2019 documented in part but not limited to the following: Policy heading Medications are administered in a safe and timely manner, and as prescribed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145382 If continuation sheet Page 11 of 11