Lamar Healthcare & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received necessary nutritional and hydration care and services to maintain nutritional status, including failing to offer alternative food items when meals were refused, failing to consistently document meal intake and weights, and failing to monitor, evaluate, and implement timely interventions, which contributed to a delay in identifying and addressing significant weight loss for one (1) of two (2) residents reviewed for nutrition. Resident #47Findings include:A record review of the admission Record revealed the facility admitted Resident #47 on 10/31/25 with diagnoses including Pressure Ulcer of Sacral Region, Stage 4. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure appropriate pain management when nursing staff failed to assess and manage pain prior to and during wound care for Resident #4 which resulted in the resident experiencing avoidable pain during wound care and failed to administer ordered pain medication for Resident #47 for two (2) of three (3) residents reviewed for pain management.

Inspectors wroteBased on interview and record review, and facility policy review, the facility failed to ensure Registered Nurse (RN) staffing was adequate to meet the needs of residents and failed to designate a licensed nurse to serve as the designated charge nurse for each tour of duty for one (1) of four (4) days of survey.

Inspectors wroteBased on record review, facility policy review and staff interview, the facility failed to ensure the Director of Nursing (DON) did not function in the capacity of the charge nurse when the facility had more than 60 residents for four (4) of (15) days reviewed for staffing. (3/16/26, 3/17/26, 3/26/26, and 3/30/26). Findings Include:A review of the facility's policy, Staffing, Sufficient and Competent Nursing, Revision Date August 2022 revealed, Sufficient Staff.2 .c. The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer. A record review of the facility's daily assignment document revealed the DON was listed as the RN (Registered Nurse) Supervisor on 3/16/26 and the census was listed as 88. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide residents with alternate food options of similar nutritive value for one (1) of (19) sampled residents with the potential to affect all 89 residents in the facility. Residents #12Findings included:A review of the facility's policy Alternate Foods for Food Preferences with reviewed date of 12/23 revealed . Alternate foods and beverages are offered to residents who refuse offered off regular menu and is, served to meet individual . preferences, or requests. Procedure: . 4. The nursing assistant, on observing that a resident is refusing food, offers the always available alternate food to the resident. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to develop and maintain a comprehensive facility assessment to determine the appropriate number of qualified staff needed to meet residents' needs, including sufficient licensed nursing staff coverage, affecting (89) of (89) residents in the facility.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to establish and maintain an effective infection prevention and control program when the designated Infection Preventionist, who was the Director of Nursing (DON), did not have sufficient time to perform infection prevention and control duties, resulting in a failure to conduct infection surveillance, track and trend infections, and perform infection control rounds for three (3) of five (5) months reviewed, which had the potential to affect all (89) residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to have verbalized grievances addressed and resolved for one (1) of (19) sampled residents. Resident #25.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to conduct a thorough investigation related to a fracture of unknown origin for one (1) of four (4) residents reviewed for accidents. Resident #47.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to notify the resident representative of the resident's transfer and failed to provide information regarding the bed-hold policy for two (2) of four (4) residents sampled for hospitalizations and closed record review. Residents #7 and #93.

Inspectors wroteBased on interviews, record review and facility policy review, the facility failed to implement comprehensive care plan interventions for three (3) of (19) sampled residents. (Resident #3, Resident #6, and Resident #25)

Inspectors wroteBased on interview and record review, the facility failed to revise a comprehensive care plan for one (1) of (19) resident care plans reviewed. Resident #47Findings include:A record review of the Care Plan Report revealed Resident #47 had an individual care plan with Focus of Impaired Skin Integrity. Stage III wound to sacrum-Healing Stage IV wound. The care plane included an intervention initiated on 1/28/26 to Remove old dressing, cleanse with wound cleanser, apply plurogel to wound to sacrum, use polymem AG (alginate) as the primary dressing, use allevyn border dressing as the secondary dressing, the order is to be carried out daily and PRN. This was inconsistent with the current physician order for wound treatment dated 2/19/26. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs) related to toenail care for one (1) of three (3) residents reviewed for ADL/Nail Care. Resident #76.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure weekly wound assessments that included wound dimensions and characteristics were completed and documented for one (1) of two (2) residents reviewed for pressure ulcers. Resident #47.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure required cautionary signage was in place for a resident receiving oxygen therapy for one (1) of (1) resident reviewed for respiratory care. Resident #45. Findings Include:A review of the facility's policy, Oxygen Administration revised October 2010, revealed, .Equipment and Supplies.4. No smoking/oxygen in use signs. Steps in the Procedure.2. Place an oxygen in use sign on the outside of the room entrance door.3. Place an oxygen in use sign in a designated place on or over resident's bed. On 3/30/26 at 12:55 PM, during an observation, Resident #45 was in bed receiving oxygen at two (2) liters per minute via nasal cannula. No oxygen-in-use signage was observed on or near the resident's door or above the resident's bed. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure appropriate monitoring and documentation of potential adverse consequences for psychotropic and high-risk medications, including anticoagulants, for three (3) of five (5) residents sampled for unnecessary medications. Resident #3, Resident #6, and Resident #25.

Inspectors wroteMS CI #25290 Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure residents dignity, physical, mental or psychosocial needs were met as evidenced by residents not receiving assistance with incontinence care in a reasonable timeframe for two (2) of 17 sampled residents. (Resident #8 and Resident #34)

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions regarding incontinence care for two (2) of 17 care plans reviewed. (Resident #8 and Resident #34) Findings Include: Record review of the facility's policy, Care Plans, Comprehensive Person Centered revised March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan .b. [...]

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed ensure that the Infection Preventionist was present in the QAPI (Quality Assurance and Performance Improvement) Committee for 12 of the 12 months of meetings reviewed. July 2023 through June 2024. This had the potential to affect the quality of healthcare for all residents residing in the facility.

Inspectors wroteBased on observation, resident and staff interview, and resident council minutes review, the facility failed to resolve resident repeated concerns of cold food served to the residents rooms for three (3) of six (6) months reviewed. January 2024, April 2024, and May 2024. Findings Include: Observation and interview on 06/25/24 1:00 PM with the Resident Council revealed 12 residents attended the meeting. Residents were comfortable and multiple residents vocalized concerns with the temperature of food served in their rooms. Residents denied issues with food temperatures served in dining room. Resident #70 stated the food temperature of eggs and other food delivered to his room are cold. Resident #54 confirmed his food was cold as well. Other residents stated this is an ongoing issue with cold food. [...]

Inspectors wroteBased on staff interviews, record reviews, and facility policy review the facility failed to ensure residents were offered Influenza and Pneumonia vaccinations as evidenced by no documentation indicating vaccinations were either offered or administered to residents who were eligible for eight (8) of the 17 sampled residents. Residents #6, #12, #13, #29, #38, #39, #48 and #70

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to provide one on one (1:1) activities for residents on isolation in the COVID-19 unit for one (1) of six (6) residents (Resident #32), with the potential to affect all residents on the unit. Findings Include: Review of the facility's policy, Activity Programs revised June 2018, revealed, Activity programs are designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation .2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes .independent individual activities .12. Individualized and group activities are provided that .c. reflect the .personal preferences of the residents . [...]

Inspectors wroteBased on observation, staff and resident interviews, record reviews and facility policy reviews, the facility failed to ensure that residents received food in a manner that was palatable and at a temperature that was satisfactory, for one (1) of 17 sampled residents.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to complete and submit quarterly Minimum Data Set (MDS) Assessments timely for seven (7) of 33 residents reviewed for MDS assessments. Resident #2, Resident #3, Resident #10, Resident #11, Resident #12, Resident #14, Resident #15

Inspectors wroteBased on observation, staff and family interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent falls for one (1) of four (4) residents investigated for falls resulting in six falls in the previous seven months for Resident #15. Findings Include: Review of the facility's, Fall-Clinical Protocol revised March 2018 revealed The staff and practitioner will review each resident's risk factors for falling and document in the medical record. The physician will identify medical conditions affecting fall risk. The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when where they happen, any observations of the event etc. The falls should be identified as witnessed or unwitnessed events. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement monitoring of meal consumption amounts for residents with weight loss for two (2) of three (3) residents reviewed for nutrition.

Inspectors wroteFinal version Based on observations, interviews, and record reviews the facility failed to revise the care plan when the desired outcome of a decrease in falls was not met for one (1) of eighteen residents, Resident #15.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to post the direct care daily staffing numbers in a location accessible to residents and visitors for four (4) of four (4) days of survey. This affected all residents in the facility. Findings Include: Record review of the facility's policy Posting Direct Care Daily Staffing Numbers with a revised date of July 2016 revealed, Policy Statement Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation 1. [...]