Inspection·November 19, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their Community Privileges and Notice of Resident Rights and Responsibilities policies by not obtaining a doctor's order or consent from the durable Power of Attorney (POA) prior to allowing a resident to leave on pass with a family member. This affected one of three residents (R1) reviewed for pass privilege policy and procedure. Findings Include: R1 was admitted on with the diagnosis of Dementia with Lewy Bodies, Traumatic Brain Injury and Cognitive Communication Deficit. R1's Brief Interview for Mental Status, dated 8/19/24, documents a score of ninety-nine, which indicates the resident was unable to complete the interview with short (recall after five minutes) and long term memory problems. R1's Community survival /risk, dated 8/10/2024, documents: Resident (R1) is new to the facility with Lewy Body and alert times one. It is recommended and agreed upon with her surrogate (V19) that resident is not capable physically or cognitively able to go into the community independently. It is recommended she may go with (V19) (ONLY) with primary care physician (PCP) order. She (V19) is aware that when leaving the property she will need to sign her off the unit and sign her back in on the floor when she returns. Nursing note, dated 10/14/24, documents: R1 accompanied by V19 went out on pass. On 11/12/24 at 2:55PM, V20 (R1's POA) said the facility called and asked when was she going to bring R1 back to the facility. V20 said she had never been to the facility to visit R1 because she lives out of the state. V20 was unable to report who called from the facility. V20 said she never gave permission for anyone to take R1 out on pass. V20 said she feared for R1's safety, and called the police to do a [NAME] being check, because the facility did not know who took R1 out on pass. On 11/13/24 at 11:21AM, V4 ( Social Service Director )said, In order for a resident to go out on pass, they must have a doctor order, completed community assessment and be safe to go out. It is the same protocol for Dementia resident, but the Power of Attorney (POA) must be notified as well. On 11/13/24 at 12:30PM, V1 (Administrator) said R1 was admitted to the facility by V19 (surrogate decision maker). V1 said, We found out about (V20, R1's POA) on 9/7/24. (V20) sent a copy of the POA paperwork with (V20's) name on it on 9/9/24. (V20) was responsible for (R1). (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 11/19/2024 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)