Lee Healthcare

Inspectors wroteBased on interviews and records reviewed, for one of five sampled employee files (Certified Nurse Aide, CNA #1), the Facility failed to ensure they implemented and followed their abuse policy related to annual training when the Facility was unable to provide documentation to support that CNA #1 had received annual abuse prohibition training as required.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was moderately cognitively impaired and prone to agitation, the Facility failed to ensure he/she was treated in a dignified and respectful manner, when on 12/20/25, despite Resident #1 verbally objecting and telling staff not to touch his/her hat, Certified Nurse Aide (CNA) #1 taunted Resident #1 by touching his/her hat twice, provoking him/her, instead of respecting his/her request.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained a complete and accurate medical record when on 10/18/25 after Resident #1 was seen by the Physician who made recommendations for interventions related to prevention of pressure injuries, there was no nursing documentation to support they were addressed or followed up on.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that professional standards of practice were implemented relative to skin and wound care for one Resident (#19) of four applicable residents reviewed for wound care, out of a total sample of 26 residents. Specifically, for Resident #19, the facility failed to: -appropriately assess and implement skin care and diabetic foot care for the Resident with a history of Diabetes, Peripheral Vascular Disease and a right below knee amputation (BKA), resulting in left toe wounds not being identified and treated timely. -submit a referral to the Wound Care Provider timely for on-going wound care when diabetic wounds were identified on the toes of the Resident's left foot. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three Nurses (Nurse #2, #3 and #4), of five Nurses reviewed, had been evaluated upon hire and/or annually to ensure skills and competencies were met relative to wound care. Specifically, for one Resident (#19) who had diabetic wounds, the facility failed to ensure Nurses #2, #3, and #4, who provided care to Resident #19, were evaluated upon hire and/or annually to ensure they had the skill sets and competencies when providing wound care.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months, for five Certified Nurse Aide (CNA #1, #2, #4, #5, and #6), out of five total records sampled. Specifically, the facility failed to ensure annual performance reviews were completed every 12 months for CNAs #1, #2, #4, #5, and #6.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Advance Directives were honored for one Resident (#11), out of a total sample of 26 residents. Specifically, for Resident #11, the facility failed to ensure that the Physician's orders accurately reflected the Resident/Resident Representative's wishes as indicated on the Medical Orders for Life-Sustaining Treatment (MOLST: legal document that allows individuals to communicate their preferences for life-sustaining treatment to healthcare providers) form, putting the Resident at risk for being resuscitated (perform full measures including cardiopulmonary resuscitation and intubation) when the advanced directive wishes were for no resuscitation (do not resuscitate [DNR]).

Inspectors wroteBased on record review and interviews, the facility failed to respond to or resolve grievances for one Resident (#54) out of a total sample of 26 residents. Specially the facility failed to respond to three grievances filed by Resident #54's family on 4/25/25.

Inspectors wroteBased on record review and interview the facility failed to ensure a Notice of Transfer or Discharge and a Bed Hold were provided to residents or their resident representatives at the time of transfer or shortly there after and that the Office of the State Long-term Care Ombudsman was notified at the time of transfer or shortly there after for one Resident (#74) out of a total sample of three residents reviewed for closed records and for one Resident (#70) out of a total of 26 active records reviewed. Specifically, 1. For Resident #74 and #70 the facility failed to ensure the Office of the State Long-term Care Ombudsman was notified when Resident #74 and #70 were transferred from the facility to the hospital, and 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed accurately to reflect the resident's status for eight Residents (#1, #3, #4, #6, #23, #31, #48, and #67), out of a total of 26 residents sampled. Specifically, for Residents #1, #3, #4, #23, #31, #48, and #67, the facility failed to ensure the Section F-Preferences for Customary Routine and Activities Assessment was completed with the Resident or a Staff Interview was completed if the Resident was unable to participate in a Resident Interview for the most recent comprehensive MDS Assessment.

Inspectors wroteBased on record review and interviews, the facility failed to ensure its staff followed professional standards for care and services relative to a suprapubic catheter (an indwelling urinary catheter placed directly into the bladder through the abdomen) and a colostomy (a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body) for one Resident (#70), out of a total sample of 26 residents. Specifically, the facility failed to obtain Physician orders on how to provide care and services for both the suprapubic catheter and the colostomy. Additionally, the facility failed to develop policies and procedures on how to provide care and services for both the suprapubic catheter and the colostomy, putting the Resident at an increased risk of infection, complications and/or improper care techniques.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an environment that was free of potential accidents and hazards and implement the facility policy to ensure smoking safety for two residents (#70 and #1) of three applicable residents reviewed for smoking, out of a total sample of 26 residents. 1. For Resident #70 the facility failed to ensure adequate supervision was provided and an individualized care plan was developed.2. For Resident #1, the facility failed to ensure that the Resident was assessed for safety prior to the Resident resuming smoking at the facility placing the Resident at risk for injury.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that the Consulting Pharmacist Medication Regimen Reviews (MRRs) were reviewed by the attending Physician timely and implemented as recommended for three Residents (#9, #31, and #8) out of a total sample of 26 residents. Specifically, for Resident's #9, #31, and #8, the facility failed to ensure that the Resident's Attending Physician reviewed and implemented or declined the Pharmacist MRRs timely.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure that complete and accurate medical records were maintained for two Residents (#8, and #11), out of a total sample of 26 residents. Specifically, for Residents #8 and #11, the facility failed to ensure that the Physician Order for nutritional supplements included the amount to be administered, placing the Residents at risk of not receiving adequate nutritional supplementation.

Inspectors wroteBased on interview, and record review, the facility failed to maintain a communication process that included maintaining documentation relative to Hospice services for one Resident (#3) out of a total sample of 26 residents. Specifically, for Resident #3, the facility failed to ensure Hospice Services documentation was readily accessible to all staff and providers for communicating necessary information regarding the resident's care between the nursing home and the Hospice.

Inspectors wroteBased on interview, and record review, the facility failed to ensure at minimum quarterly Quality Assurance Performance Improvement (QAPI) meetings were held during one quarter, out of four quarters reviewed. Specifically, the facility failed to ensure that a QAPI meeting for October 2024, was completed as scheduled quarterly to identify issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that antibiotic use was monitored for one Resident (#5), of five applicable residents reviewed for unnecessary medication review, out of a total sample of 26 residents. Specifically, for Resident #5, the facility failed to ensure a prophylactic antibiotic was monitored and re-evaluated for continued use of the antibiotic.

Inspectors wroteBased on record review, and interview, the facility failed to ensure one Resident (#5), of five applicable residents reviewed for immunizations, out of a total sample of 26 residents, was offered to receive or decline the COVID-19 vaccine. Specifically, for Resident #5, the facility failed to offer and provide the COVID-19 vaccine when he/she was not up to date with the COVID-19 vaccination.

Inspectors wroteBased on observation and interview, the facility failed to maintain sanitary and safe conditions for two unit kitchenettes (Unit One and Unit Two) out of two unit kitchenettes. Specifically, the facility failed to maintain clean and sanitary conditions for the toasters in both Unit One and Unit Two kitchenettes that presented a fire risk.

Inspectors wroteBased on observation, interview and policy review, the facility failed to maintain a clean and homelike environment on one (Unit One) out of two Units observed. Specifically, the facility staff failed to clean a resident's room with visible marking/drippings on the wall.

Inspectors wroteBased on interview and record the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide care in accordance with professional standards of practice relative to the application and monitoring of a wound dressing for one Resident (#201) out of a total sample of 14 residents. Specifically, the facility staff failed to: -accurately assess Resident's #201 skin. -obtain a Physician's order for a dressing that was applied to the Resident's left elbow. -provide on-going assessment of the left elbow area resulting in the applied dressing not being changed timely and putting the Resident at risk for worsening wound status and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a discharge summary was completed for one Resident (#35) out of a total sample of 14 residents. Specifically, for Resident #35, the facility failed to ensure that: -a post discharge plan of care was developed with the participation of the Resident. -a discharge summary was completed at the time of discharge that included any arrangements that had been made for the Resident's follow-up care. -communication was provided to continuing care providers.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive Trauma Informed Care Plan for one Resident (#35)out of a total sample of 14 residents. Specifically, for Resident #35, the facility failed to complete an assessment and ensure that a comprehensive Trauma Informed Care Plan was developed relative to the Resident's history of PTSD (Post -Traumatic Stress Disorder- a mental and behavioral disorder that develops from having experienced a traumatic event, causing flashbacks, nightmares and severe anxiety).

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Certified Nurses Aide (CNA) documentation was complete and accurate for one Resident (#1) out of a total sample of 14 residents. Specifically, for Resident #1, the facility failed to ensure CNA documentation related to meal intake was documented every shift for the Resident who had a history of significant weight loss and was at increased risk for nutritional decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC - - notice issued to a resident who is receiving benefits under Medicare Part A when all covered services end) and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN - notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for one Resident (#36) out of a total applicable sample of three residents. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide a written Notice of Transfer and Discharge to the Resident and Resident's Representative at the time of discharge for one Resident (#40) out of a total sample of 14 residents. Specifically, the facility staff failed to provide Resident #40/ Resident Representative a written Notice of Intent to Transfer and Discharge when the Resident was transferred from the facility to the hospital.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice and the comprehensive care plan for five Residents (#3, #39, #42, #28, #103) out of six applicable residents with respiratory care needs, out of a total sample of 15 residents and one closed record for Resident (#51) out of a total sample of two closed records. Specifically, the facility failed to ensure its staff: -posted signage relative to Oxygen (O2) use, -delivered O2 at the prescribed flow rate, -labeled, dated, and stored oxygen tubing and respiratory equipment properly between use, -and had comprehensive orders in place for the use and care of Continuous Positive Airway Pressure machines (CPAP- machine used to treat sleep apnea that involves the administration of a pre-determined level of pressure through a facial mask).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its staff notified the attending Physician of a recommendation from the Wound Care Specialist for one Resident (#22) out of 15 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN- a notice to inform a resident or resident representative that skilled Medicare services will no longer be covered and to inform them of the cost they may be responsible to pay), for two Resident's (#9 and #11) out of a total of three sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff reviewed and revised the care plan after each assessment, for two Residents (#2 and #39) out of a total sample of 15 Residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure its staff obtained recommended Behavioral Health Services for one Resident (#35) out of a sample of 15 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff indicated a duration for an as needed (PRN) Psychotropic medication (a medication that affects brain activities associated with mental processes and behavior) for one Resident (#39) out of a total sample of 15 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure its staff maintained the daily posting of the nursing staffing data with current information. During an observation on 5/7/23 at 10:07 A.M., the daily Nursing Staffing Form was posted in the entrance area. The form was dated 4/21/23. During an interview on 5/9/23 at 10:42 A.M., with the Scheduler and Administrator, the Scheduler said that she posted the required staffing form daily in the lobby but had been out of the building on vacation and that it had not been done as required. The Administrator said that the purpose of the daily posting was to inform the residents and visitors of the amount of nursing staff working daily.

Inspectors wroteBased on record review and interview, the facility failed to ensure the arbitration agreement, signed by residents or their representative, explicitly stated: 1. The resident or his/her representative had the right to rescind the agreement within 30 calendar days of signing it, and 2. that neither the resident nor his/her representative was required to sign an agreement as a condition of admission to, or as a requirement to continue to receive care at the facility, for three Residents (#20, #29 and #41) out of a total sample of three residents.