Lee Manor

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate transfer for a resident who is Dependent for transfers requiring a mechanical lift transfer with 2 persons transfer assist due to being non-ambulatory. This deficiency affects one (R210) of three residents reviewed for accidents and incidents. This failure resulted in R210 to have a right lower leg laceration requiring 12 stiches.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care to dependent residents. This applies to 4 of 4 residents (R1-R4) reviewed for incontinence care in a sample of 4.

Inspectors wroteBased on interviews and records reviewed the facility failed to complete a wound assessment and document treatment and findings of the assessment of one resident (R91) who developed a reddened area on her left and right buttock, and failed to ensure there were effective interventions to prevent further deterioration. This failure affected one of five of 5 (R91) reviewed for pressure ulcers in a sample of 36. This failure resulted in R91 developing an unstageable pressure ulcer that required debridement.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their practice and provide 2 person assist with bed repositioning of a dependent resident. This failure affects one of three residents (R91) reviewed for falls. This failure resulted in R91 falling out of bed when staff turned her and sustained head injury requiring 1 staple to the back of her head.

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and develop effective interventions to prevent residents from experiencing unplanned significant weight loss. This affected three of eight residents (R49, R109, and R145) reviewed for weight loss and weight loss prevention. This failure resulted in unplanned weight loss for R49 of 14% in six months, R109 8% in one month, and R145 10% in one month. Findings Include: A. R49 is a [AGE] year old with the following diagnosis: Alzheimer's disease, vascular dementia, hypertensive heart disease with heart failure, and dysphagia. A Nursing note dated 3/9/25 documents R49 refused to eat even though staff attempted to feed. There is no notification the physician was notified of poor appetite. A Nursing note dated 3/10/25 documents R49 is still having a poor appetite. R49 verbalized being hungry but is not eating food. [...]

Inspectors wroteBased on interview and record review, the facility failed follow the Physician Notification in Change of Condition Policy by not notifying MD (Doctor of Medicine) about medications administered late. This failure affected one resident (R157) of eight residents reviewed for notification.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate an appointment with the audiologist to remove hardened ear wax from a resident's bilateral ear canals causing an increase in hearing loss for one out of one (R73) resident reviewed for hearing loss in a total sample of 36. Findings Include: R73 is a [AGE] year old with the following diagnosis: Alzheimer's disease, Parkinson's disease, vascular dementia, and paraplegia. The Audiology Progress note dated 12/18/24 documents R73 had a very hard time communicating because R73 could not hear what was being said even while wearing headphones with amplified microphone. R73 reports having poor hearing, but recently, it seems to have gotten worse. Wax was noted in both ears and removal was attempted. In the right ear, about half of the wax was successfully removed. [...]

Inspectors wroteBased on observations, interviews, and records reviewed the facility failed to accurately assess the number of side rails appropriate for one of one resident's (R137) use of side rails in a sample of 36.

Inspectors wroteBased on observation and interview, the facility failed to post Nurse Staffing Data in a prominent area available for residents and visitors. This failure has the capacity to affect all residents.

Inspectors wroteBased 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: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices during medication administration by failure to disinfect medical equipment such as blood pressure (BP) apparatus and oximeter after each resident use. This deficiency affects all four (R65, R82, R124 and R150) residents in the sample of 35 reviewed for infection control during Medication Administration.

Inspectors wroteBased on the interview and record review, the facility failed to prevent resident-to-resident physical assault. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 hitting R1 in the face.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure comprehensive, personalized activity care plans were completed for vulnerable residents. This failure applied to two (R13 and R118) of 35 residents reviewed for activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personalized activities were provided for vulnerable residents based on their interests, preferences and needs. This failure applied to two (R13 and R118) of 35 residents reviewed for activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete Abnormal Involuntary Movement Scale (AIMS) assessments every six months for monitoring of side effects while using antipsychotic medication for a resident who was exhibiting signs of sudden, irregular facial movements. This failure applied to one (R18) of five residents reviewed for unnecessary medications in sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication administration error rate below 5%. There were 25 opportunities with two errors resulting in an 8% medication error rate observed. This failure applied to two (R83 and R177) of two residents reviewed during the medication administration task.