Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lee Manor during CMS and state inspections, most recent first.
Surveyors found that staff failed to provide timely incontinence care to four cognitively impaired, toileting-dependent residents. Multiple residents were observed late in the morning with urine-soaked briefs, brownish discoloration, and wet linens, despite care plans requiring frequent toileting assistance and peri-care with each incontinent episode. CNAs reported not having changed some residents since early morning, using double briefs on a resident who voided frequently, and planning to change residents only when they were next seen, while the DON later acknowledged that leaving residents in urine-soaked briefs and using two diapers was not acceptable.
A resident with significant cognitive and physical impairments developed a pressure ulcer that was not properly assessed or documented after initial signs of skin breakdown were observed. Despite verbal reporting by a CNA, no formal wound assessment or documentation occurred, and treatment orders were inconsistently recorded in the TAR. The wound progressed and required debridement, with facility policies for wound care assessment and documentation not followed.
A dependent, nonverbal resident with multiple diagnoses, including Alzheimer's and Parkinson's, was injured after falling from bed when a CNA attempted to reposition her alone, contrary to facility practice requiring two-person assist for such residents. The resident sustained a head laceration that required a staple, and the care plan did not specify the required level of assistance.
Three residents experienced significant unplanned weight loss due to the facility's failure to identify, assess, and implement effective interventions. In each case, there were missed notifications to physicians and dietitians, lack of timely dietary follow-up, missing or incomplete documentation of calorie counts, and care plans that were not updated in response to ongoing poor intake and weight loss.
A nurse administered medications, including an antibiotic, to a resident nearly two hours late without notifying the MD or documenting the reason for the delay, as required by facility policy. Staff interviews confirmed that neither physician notification nor proper documentation occurred for the late administration.
A resident with severe cognitive and physical impairments experienced worsening hearing loss due to hardened ear wax that was not fully removed as recommended by an audiologist. Facility staff did not coordinate a timely follow-up appointment for further wax removal after a COVID-19 outbreak, and the resident remained unable to hear or communicate effectively despite the use of hearing aids and alternative communication methods.
A resident with significant mobility and cognitive impairments was found with both upper and lower quarter side rails and bolsters in use, but staff were inconsistent in their knowledge of the intended number of rails and lacked assessments for the bolsters. The care plan did not specify the number of rails or mention bolsters, and documentation failed to clearly address the devices in use, resulting in a deficiency related to inadequate assessment and documentation of side rail use.
Surveyors determined that required daily Nurse Staffing Data was not posted in a prominent area for residents and visitors. The DON and Administrator confirmed the absence, attributing it to the scheduler being on leave, and the Receptionist had not seen the data that morning.
A resident with multiple health issues was found unresponsive after a shower, leading to a delayed 911 call. The resident suffered a blunt force head injury, likely from a fall, resulting in extensive intracranial hemorrhage and death. The facility failed to determine the cause of the injury, contributing to the resident's deteriorating condition.
A resident with dementia was allowed to leave the facility without a doctor's order or consent from their POA. The resident, who had significant cognitive impairments, was taken out by a surrogate decision maker without proper authorization. The facility failed to notify the POA, who was unaware and concerned for the resident's safety, leading to police involvement. Documentation confirmed the lack of required authorization.
The facility failed to implement appropriate infection prevention and control practices during medication administration by not disinfecting medical equipment such as blood pressure apparatus and oximeter after each resident use. The RN used the same equipment on multiple residents without disinfecting it between uses, despite the facility's policy requiring disinfection to prevent the spread of infection.
Failure to Provide Timely Incontinence Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and toileting hygiene to dependent residents, as identified through observation, interview, and record review. Four residents with documented severe or moderate cognitive impairment and dependence on toileting hygiene were found with urine-soaked briefs and wet linens late in the morning. One male resident was observed in bed pointing to his soaked incontinent brief at 9:40 AM; a CNA who had started work at 7:00 AM acknowledged she had not yet changed him. His care plan included cleaning the peri-area with each incontinent episode. Another male resident was observed at 10:10 AM lying on a low bed wearing two incontinent briefs with wet mattress linens; the inner brief was urine-soaked with brownish discoloration. The CNA caring for him stated that she put two diapers on him because he urinated a lot and planned to change him to one diaper, despite his care plan directing staff to assist him by toileting frequently. A female resident with moderate cognitive impairment and dependence on toileting hygiene was observed at 10:15 AM in bed with a brownish discolored, urine-soaked incontinent brief. The CNA reported that this resident had last been changed around 7:00 AM by the night CNA and that she was going to change her at that time, although the care plan called for frequent toileting assistance. Another female resident with severely impaired cognition and dependent on toileting hygiene was observed at 10:20 AM with a urine-soaked brief showing brownish discoloration through to the outside of the brief and mild wet padding. A hospice CNA stated she visits this resident twice per week and was going to change her then. This resident’s care plan required incontinence care after every diaper change. The DON stated that it was not acceptable to leave residents in urine-soaked, brownish-colored briefs and referenced the issue of staff putting two diapers on residents and the need to check residents frequently.
Failure to Assess, Document, and Treat Pressure Ulcer Leads to Wound Deterioration
Penalty
Summary
A resident with multiple diagnoses, including Alzheimer's Disease, Parkinson's Disease, diabetes, and vascular dementia, was found to have developed a pressure ulcer while under the care of the facility. The resident was completely dependent on staff for mobility and personal care, requiring regular turning and repositioning. Despite a certified nursing assistant (CNA) observing a reddened area on the resident's buttocks and verbally reporting it to a nurse, there was no documentation or formal wound assessment completed at that time. The CNA continued to apply barrier ointment and turn the resident, but the initial signs of skin breakdown were not formally recorded or addressed in the medical record. The wound care nurse later confirmed that the area was red and classified it as a superficial Stage 1 pressure injury but did not document an assessment. The wound care nurse was then absent on vacation, and the wound was not reassessed or documented until a hospice nurse identified a new pressure ulcer on the sacrum several days later. The wound was initially coded incorrectly in the Minimum Data Set (MDS) and was not properly staged or documented as a deep tissue injury. Treatment orders for the wound were not consistently entered into the Treatment Administration Record (TAR), and some prescribed treatments were missing from the record, making it unclear whether they were administered as ordered. The facility's own policies required full assessment and documentation of pressure sores, including location, stage, and measurements, as well as ensuring physician orders for wound care procedures. These protocols were not followed, resulting in a lack of timely and accurate documentation, incomplete treatment records, and a failure to implement effective interventions to prevent further deterioration. As a result, the resident's pressure ulcer progressed to an unstageable wound requiring debridement.
Failure to Provide Required Two-Person Assist During Bed Repositioning Results in Resident Fall and Head Injury
Penalty
Summary
A dependent resident with multiple diagnoses, including Alzheimer's Disease, Parkinson's Disease, vascular dementia, and a cognitive communication deficit, experienced a fall from bed resulting in a head injury that required a staple. The resident was nonverbal and required assistance with activities of daily living. According to the facility's practice, such a resident should have been repositioned in bed with the assistance of two staff members. However, on the date of the incident, a CNA attempted to turn the resident alone, during which the resident slid off the bed and sustained a laceration to the back of the head. Interviews with facility staff confirmed that the resident was dependent and should have received a two-person assist for bed repositioning. The Assistant Director of Nursing and the Restorative Nurse both stated that dependent residents require two staff for repositioning. The resident's care plan and assessment did not specify the number of staff required for assistance, and the CNA involved in the incident was not available for interview. The incident report and progress notes documented the fall and subsequent injury, as well as the resident's return from the hospital with a staple applied to the head wound.
Failure to Prevent and Address Significant Unplanned Weight Loss
Penalty
Summary
The facility failed to identify, assess, and implement effective interventions to prevent unplanned significant weight loss in three residents. For one resident with Alzheimer's disease, vascular dementia, heart failure, and dysphagia, there were repeated nursing notes documenting poor appetite, refusal to eat, and minimal intake over several weeks. Despite these ongoing issues, there was inconsistent notification to the physician, lack of timely dietary follow-up, and no new interventions added for months. The resident experienced a 14% weight loss over six months, with documentation showing variable and often poor intake, and no evidence of completed calorie counts as ordered. The dietitian was not notified of significant weight loss in March, and interventions remained unchanged despite continued decline. Another resident with Alzheimer's disease, vascular dementia, and heart failure experienced an 8% weight loss in one month. There was no documentation that the physician was notified of the weight loss in March, and dietary notes were missing for February and March. Although a calorie count was ordered, there was no evidence it was completed or reviewed. The dietitian confirmed not being notified of the weight loss and did not follow up on the calorie count. Interventions in the care plan were not updated in response to the ongoing weight loss, and the resident's intake remained variable and often poor. A third resident with malignant neuroendocrine tumors, gastrostomy, and dysphagia experienced a 10% weight loss in one month. The resident was hospitalized and returned with a G-tube, but there was no documentation of new interventions to address the weight loss prior to hospitalization. The dietitian was not notified of the weight loss before the resident left for the hospital, and the care plan lacked updated interventions for nutritional risk. Weights were inconsistently documented, and the facility's process for monitoring and responding to significant weight loss was not followed as outlined in their policies.
Failure to Notify Physician and Document Late Medication Administration
Penalty
Summary
A deficiency occurred when a registered nurse administered medications, including Doxycycline, Eliquis, and Amlodipine, to a resident nearly two hours after the scheduled 9:00 AM administration time. The facility's policy requires that the physician be notified of late administration of certain medications, such as antibiotics like Doxycycline, and that a note be documented explaining the delay. However, there was no documentation in the nursing progress notes regarding physician notification or an explanation for the late administration. Interviews with nursing staff and the Director of Nursing confirmed that the required notifications and documentation were not completed for this incident. The resident's medication administration record reflected the late administration, but no further action was documented as required by facility policy.
Failure to Coordinate Timely Audiology Follow-Up for Hearing Loss
Penalty
Summary
The facility failed to coordinate timely follow-up care for a resident with significant hearing loss due to hardened ear wax in both ears. The resident, who has diagnoses including Alzheimer's disease, Parkinson's disease, vascular dementia, and paraplegia, was noted by an audiologist to have severe wax buildup that was only partially removed during an initial visit. The audiologist's plan included the use of wax softening drops and a follow-up appointment for further removal, but this follow-up did not occur as scheduled. During a COVID-19 outbreak, the facility restricted outside physician visits, which delayed the resident's access to the audiologist. After the outbreak ended, staff did not reschedule the audiologist's visit for the resident, and the resident was not seen during the next available audiology visit. Staff interviews revealed a lack of awareness regarding the resident's need for further ear wax removal and the audiologist's recommendations. The resident continued to experience severe hearing impairment, with staff and family noting that hearing aids were ineffective and communication was significantly hindered. Documentation showed that the resident received wax softening drops as ordered, but the necessary follow-up for wax removal was not arranged. The care plan identified the resident's highly impaired hearing and recommended referral to an ear, nose, and throat doctor for wax removal, but this intervention was not implemented. Staff continued to use alternative communication methods, such as writing and speaking loudly, but these were ineffective due to the resident's concurrent vision impairment and lack of updated glasses.
Failure to Accurately Assess and Document Side Rail Use
Penalty
Summary
The facility failed to accurately assess and document the appropriate use and number of side rails for a resident who was observed with bolsters, quarter side rails on both the upper and lower sections of the bed, and floor mats in the room. Staff interviews revealed that the resident was dependent on staff for mobility, unable to turn or get out of bed without assistance, and had cognitive impairments including confusion and impaired decision-making. Despite these conditions, there was inconsistency among staff regarding the intended use of the side rails and bolsters, with some staff unaware of the number of rails in use or the need for an assessment for the bolsters. The care plan did not specify the number of side rails to be used or include any mention of bolsters. Documentation provided by the facility included a consent form and assessment for the use of a quarter side rail as an enabler, but it did not specify the number of rails or address the use of bolsters. The care plan was updated to reflect the use of the device for the resident's independence and psychological well-being, but lacked details on the specific devices in use. The lack of clear assessment, documentation, and communication regarding the use of side rails and bolsters led to the deficiency identified during the survey.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
Surveyors found that the facility failed to post daily Nurse Staffing Data in a prominent area accessible to residents and visitors. During a tour of the first floor, the surveyor was unable to locate the required staffing information and confirmed this with the DON, Administrator, and Receptionist. The Receptionist stated she had not seen the Nurse Staffing Data that morning, and the DON explained that the scheduler, who is responsible for posting the data, was on vacation. The Administrator further confirmed that the scheduler was on Family Medical Leave of Absence and that the Nurse Staffing Data, which should be posted at the front desk, was not posted earlier that morning. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Identify Blunt Force Injury Leads to Resident's Death
Penalty
Summary
The facility failed to determine the cause of a blunt force head injury for a resident, identified as R2, which resulted in severe consequences. R2 was admitted with multiple diagnoses, including acute heart failure, dementia, and hypertension. On the day of the incident, a CNA reported that R2 was not feeling well after a shower. Despite being awake, R2 was unresponsive to questions, prompting the staff to call 911. The ambulance report noted that R2 was found unresponsive in bed, with a primary impression of a stroke and a mechanism of injury marked as blunt force trauma, possibly from a fall. The hospital records indicated that R2 had extensive intracranial hemorrhage and edema, with a CT scan showing significant brain injuries consistent with blunt force trauma. The medical examiner attributed R2's death to complications from an intracranial hemorrhage due to a probable fall, although it was not witnessed. The report highlights that the injury was acute and likely occurred quickly, leading to R2's unresponsiveness and subsequent death. The facility's failure to promptly identify and address the injury contributed to the resident's deteriorating condition and eventual death.
Failure to Obtain Proper Authorization for Resident Outings
Penalty
Summary
The facility failed to adhere to its Community Privileges and Notice of Resident Rights and Responsibilities policies by allowing a resident diagnosed with Dementia with Lewy Bodies, Traumatic Brain Injury, and Cognitive Communication Deficit to leave the facility without obtaining a doctor's order or consent from the resident's durable Power of Attorney (POA). The resident, who was unable to complete a mental status interview due to memory problems, was taken out on pass by a surrogate decision maker without the required authorization. The facility's records indicated that the resident was not capable of going into the community independently and required a physician's order to leave with the surrogate. The deficiency was further compounded when the facility contacted the POA, who lived out of state and had never visited the facility, to inquire about the resident's return. The POA, unaware of the resident's outings, expressed concern for the resident's safety and involved the police. The facility's staff, including the Social Service Director and Administrator, acknowledged the oversight, noting that the POA should have been notified and a doctor's order should have been obtained before the resident was allowed to leave the facility. The facility's documentation, including the physician order sheet and out on pass sign-out sheet, confirmed the lack of proper authorization for the resident's outings.
Failure to Disinfect Medical Equipment Between Resident Uses
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during medication administration by not disinfecting medical equipment such as blood pressure (BP) apparatus and oximeter after each resident use. This deficiency was observed with four residents. The Registered Nurse (RN) used the same BP cuff and pulse oximeter on multiple residents without disinfecting them between uses. Specifically, the RN took vital signs of four residents consecutively without disinfecting the equipment, despite the facility's policy requiring disinfection after each use to prevent the spread of infection. The RN acknowledged forgetting to disinfect the equipment, and the Infection Control Coordinator confirmed that the equipment should be disinfected after each resident use. The facility's policy on Cleaning and Disinfection of Resident-Care Items and Equipment mandates that non-critical resident care items, such as BP cuffs, must be cleaned and disinfected before reuse by another resident. The policy also outlines the use of various germicidal detergents for intermediate and low-level disinfection of non-critical items.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Des Plaines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care Des Plaines | 0.6 mi | ★★★★★ | 4 | 0 |
| Alden Des Plaines Rehab & Hc | 1.7 mi | ★★★★★ | 4 | 0 |
| Ascension Nazarethville Place | 1.9 mi | ★★★★★ | 3 | 0 |
| Rivaya Care Of Des Plaines | 2.1 mi | ★★★★★ | 9 | 0 |
| Asbury Court Nursing & Rehab | 2.4 mi | ★★★★★ | 2 | 0 |
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