Lamar Estates Nursing Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to have a system in place to ensure all residents were offered and received an updated COVID-19 vaccination which matched the current variants. Record review revealed the facility was in outbreak status when nine residents tested positive for COVID-19 on 1/13/26. Within the next 14 days, an additional seven residents tested positive for COVID-19. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#3) of four residents reviewed for ancillary services out of 27 sample residents received 24-hour emergency dental care. Resident #3 was admitted on [DATE]. On 11/24/25 the resident lost a filling from her tooth. Resident #3 reported the issue to the nurse. The tooth became jagged from the missing filling. Resident #3 reported pain, difficulty eating and that a sore developed on her tongue. The facility failed to assist the resident with dental services for 34 days, resulting in the resident's continued pain. On 12/30/25, the resident saw the dentist and had immediate relief following the dentist smoothing the tooth. Specifically, the facility failed to ensure Resident #3 was provided timely dental services after reporting a missing filling.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every certified nurse aide (CNA) at least once every 12-months and provide regular in-service education based on the outcome of these reviews for five of five CNA.Specifically, the facility failed to complete annual performance reviews and provide regular in-service education which was based on the outcome of the reviews for CNA #1, CNA #3, CNA #4, CNA #5 and CNA #6.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for one of one unit. Specifically, the facility failed to:-Ensure correct transmission based precautions signage was posted on resident rooms;-Ensure staff wore appropriate personal protective equipment (PPE) while providing care to a resident requiring droplet precautions;-Follow infection control wound care guidelines for dressing changes;-Ensure housekeeping staff performed hand hygiene after glove removal and nursing staff used hand hygiene during medication administration; and,-Clean pulse oximetry equipment after contamination.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for two (#2 and #20) of five residents reviewed for unnecessary medications out of 27 sample residents. Specifically, the facility failed to:-Develop and implement a comprehensive care plan for Resident #2's pain medications and anxiety medications; and, -Develop and implement a comprehensive care plan for Resident #20's depression medications Resident #2 and Resident #20.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#22) of one resident reviewed for insulin administration out of 27 sample residents was kept free from significant medication errors. Specifically the facility failed to ensure the insulin pen was primed prior to an insulin medication administration for Resident #22

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications for one of one medication storage room and one of one medication storage cart. Specifically, the facility failed to:-Date a resident's semaglutide pen with the date it was opened; -Discard medication that had expired; and,-Discard undated opened medication (tuberculin purified protein) from a medication refrigerator.

Inspectors wroteBased on record review and staff interviews the facility failed to provide services for six (#2, #3, #6, #12, #15 and #17) out of nine sample residents according to professional standards of practice. Specifically, the facility failed to clarify physician's orders with dose information for the administration of topical skin medications for Residents #2, #3, #6, #12, #15 and #17.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure comprehensive person-centered care plans were developed in accordance with professional standards of practice for three (#13, #15 and #19) of twelve reviewed out of 24 sample residents. Specifically, the facility failed to ensure a comprehensive care plan was initiated for: -Resident #15 for depression; -Resident #19 for urinary catheter care; and, -Resident #13 for hospice care and services.

Inspectors wroteBased on record review and interviews, the facility failed to ensure certified nurse aides (CNA) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure CNA staff had completed competencies prior to providing cares for four out of four CNAs reviewed for competencies.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for two (#6 and #2) of two residents reviewed out of 15 sample residents. Specifically, the facility failed to provide adequate supervision and effective interventions to prevent a resident-to-resident physical altercation between Resident #2 and #6. Cross-reference F744 for failure to provide adequate dementia management care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#7) of three residents reviewed for oxygen therapy out of 15 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Residents #7.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that a resident who displays or was diagnosed with mental disorder receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one (#7) of 15 sample residents. Specifically, the facility failed to identify behaviors and develop a person-centered individualized care plan to include interventions to address identified inappropriate and/or disruptive behaviors for Resident #7. I. Facility policy The Behavioral Assessment, Intervention, and Monitoring policy, revised in March 2019, was provided by the nursing home administrator (NHA) on 6/29/22 at 12:17 p.m. via email. The policy stated: Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who displays or was diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being; most pertinent to one (#2) of two residents reviewed for dementia care out of 15 sample residents. Specifically the facility's failure to: -Provide Resident #2 with sufficient supervision/monitoring and interventions as care planned, to prevent the resident from getting into physical resident-to-resident altercations, where a non-aggressive dependent resident was hit in the head (Cross-reference F600 for abuse); and, -Identify and address Resident #2's escalating behavior following a blood glucose finger stick and insulin injection (Cross-reference F600); [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of one medication storage rooms. Specifically, the facility failed to ensure the medication storage room was secure with wandering residents nearby. I. Facility policy The Storage of Medication policy, revised in November 2020, was provided by the nursing home administrator (NHA) on 6/29/22 at 12:49 p.m. via email. The policy included: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. II. Observation and interview The medication storage room was propped open on 6/26/22 at 2:15 p.m. There were two residents wandering in the hallway at the same time. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for two (#6 and #12) of five residents reviewed for immunizations out of 15 sample residents. Specifically, the facility failed to offer and provide the pneumococcal conjugate vaccine (PCV13) and or pneumococcal polysaccharide vaccine (PPSV23) to Resident #6 and #12.