Inspection·September 11, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to prevent resident-to-resident physical assault. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 hitting R1 in the face. The findings include: R1 is a [AGE] year-old male with cognition intact as per the Minimum Data Set (MDS), dated [DATE]. R2 is a [AGE] year-old male with moderate cognitive impairment per MDS, dated [DATE]. Record review on reportable documented a physical abuse between R1 and R2 on 8/5/23. On 9/9/23 at 10:30 AM, R1 stated, A long time ago, one guy hit me. He is not a good guy, and he is on the first floor now. My roommate tried to go through the door while I was on his way (R1 and R2 were in wheelchairs). He told me to move, and I said go ahead. Then he hit me in the face. It hurt me so .so. I didn't have any bleeding/swelling. On 9/9/23 at 10:40 AM, V3 (R1's Registered Nurse/RN) stated, I was giving medications to (resident room) when I heard (R1) screaming. (R1) came to the nurse's station, and I met him in front of the nurse's station. (R1) said his roommate (R2) hurt him. When I assessed (R1), there was no injury, bleeding, or swelling. On 9/9/23 at 10:40, V3 added, Both (R1) and (R2) were roommates. On 8/5/23, (R1) said something bad, and (R2) hit him in the face. The police questioned (R2), and he admitted that he hit (R1). (R2) stated he would hit him again if (R1) said bad words. On 9/9/23 at 12:35 PM, V5 (Certified Nursing Assistant/CNA) stated, On 8/5/23, when I heard (R1) screaming at around 9:00 AM, I was in the nurse's station entering data (how much each resident ate, transfer assist/locomotion, etc.) on to my tablet. I saw (R2) punching (R1). I asked him what you are doing and separated them. (R1) was blocking (R2's) way to exit his room. (R2) punched only once, and there was no injury or bleeding. Both residents were wheelchair users. On 9/9/23 at 11:00 AM, R2 was observed in his wheelchair in his room and stated, I don't know why they moved me to the fourth floor from the second floor. My old roommate (R1) called me something st .d, and I hit him in his face. He wasn't bleeding or in pain. (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 09/11/2023 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)