Health inspection·March 22, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices during medication administration by failure to disinfect medical equipment such as blood pressure (BP) apparatus and oximeter after each resident use. This deficiency affects all four (R65, R82, R124 and R150) residents in the sample of 35 reviewed for infection control during Medication Administration. Residents Affected - Some Findings include: On 3/19/2024 at 10:54AM, V12, RN (Registered Nurse), said she will take vital signs of R150 before giving his medications. V12 placed the BP cuff to R150's left arm and pulse oximeter on left index finger. V12 obtained BP 129/81mmhg (millimeter of mercury) and Oxygen (O2) saturation of 97%. V12 did not disinfect medical equipment (BP cuff and oximeter) used with R150 and prepared his medications. On 3/19/24 at 11:10AM, V12, RN, said that she will take vital signs of R124 before giving her medications. Without disinfecting the medical equipment used from another resident, V12 placed the BP cuff on R124's right arm and placed the pulse oximeter on right index finger. V12 obtained BP 128/76mmhg and O2 saturation of 95%. V12 did not disinfect medical equipment used with R124 and prepared her medications. On 3/19/24 at 11:34AM, R65 requested V12, RN, to take her vital signs. V12 took the same medical equipment, without disinfecting it. V12 placed the BP cuff to R65's left arm and pulse oximeter on left index finger. V12 obtained BP112/66mmhg and O2 saturation of 99%. V12, RN, did not disinfect the medical equipment after using it. On 3/19/24 at 11:38AM, V12, RN, said she will take R82's vital signs before giving her medications. V12 took the same medical equipment, without disinfecting it. V12 placed BP cuff around right arm and pulse oximeter on right index finger. V12 obtained BP 125/83mmhg and O2 saturation of 96%. V12 did not disinfect the medical equipment with R82 and prepared her medications. On 3/19/24 at 12:05PM, V12 said she should disinfect the BP cuff and pulse oximeter after each resident. V12 said she just forgot to disinfect it. On 3/19/24 at 12:35PM, V6, Infection Control Coordinator, said medical equipment such as BP cuff and pulse oximeter should be disinfected after each resident use. V6 added, It is a must to clean it, to prevent spread of infection. Facility's policy on Cleaning and Disinfection of Resident-Care Items and Equipment indicates: (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 03/22/2024 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)