Health 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). Page 1 of 2 145382 145382 11/19/2024 Lee Manor 1301 Lee Street Des Plaines, IL 60018

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/14/24 at 10:13AM, V10 (Social Service) said she was not aware of V20 until a week after R1's admission. V10 said, In order for a resident to go out on pass, the resident must have a doctor order. (R1) did not have a doctor's order to go out on pass. (V20) was not called either time when (R1) went out on pass with (V19). (V19) did not have (V20's) authorization to take (R1) out on pass. (R1) was not verbal upon admission, and would stare at staff when spoken to. Towards the end of (R1's) stay, (R1) could answer yes or no to basic care needs questions. V10 said she was informed V20 should have been the contact person for R1. R1's physician order sheet did not document an order to go out on pass. Out on pass sign out sheet, dated 10/14/24 and 10/22/24, documents: V19 signed out R1 destination outside. Police report, dated 10/21/24, documents: V20 stated V19 took R1 from the nursing home without V20's permission. V20 stated she is R1's POA. The facility called V20 asking when she was going to bring R1 back to the facility. V20 stated she did not have R1 because V20 lives out of state. V20 asked the employee who took R1, and they stated V19. V20 told the police V19 was not allowed to have access to R1. Durable Power of Attorney, notarized on 7/10/16, documents: appoint (V20) to be my true and lawful agent for (R1) and on my behalf to perform all such acts as my agent in his/her absolute discretion may deem advisable, as fully as I could do if personally present. This Power of Attorney is durable and shall not be affected my subsequent disability or incapacity. Expect as otherwise stated in this Power of Attorney, my Agent is given the fullest powers to act on my half. To authorize my admission to a medical, nursing, residential, or similar facility and to enter into agreement for my care. To make or do any of the following (use this space to list any additional powers you want your agent to have): to rectify situation that affect my physical and/or mental health. This power of attorney shall not expire by reason of lapse of time. This Power of Attorney shall be revoked by my giving my agent written notification on the revocation. Community Privileges policy, dated 9/2005, documents: Out on pass order will be obtained. Notice of resident rights and responsibilities policy no date documents: Should a resident be adjudicated incompetent or identified as lacking decision making capacity, the resident's representative (sponsor) shall act in behalf of the resident. 145382 Page 2 of 2