Lemay Nursing

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure on-going resident centered therapeutic activities were provided to residents in the evenings and on weekends as an integral part of their psychosocial well-being. In addition, the facility failed to ensure that 1 on 1 activities were done more than one time a week. This deficient practice had the potential to affect all residents in the facility. The census was 46. 1. Review of the facility's May 2025 activity calendar, showed: -Monday through Friday, no activities offered after 2:00 P.M.; -Saturdays: 5/3/25, Self Directed Activities, 10:00 A.M., Bingo with volunteer and 3:30, House of Prayer Music Visit. 5/17/25 and 5/31/25 included bingo with volunteer at 10:00 A.M. All other Saturdays were Self Directed Activities, which included coloring, word puzzles, card and board games; -Sundays: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and ensure side rails were assessed as necessary on a quarterly and annual basis for six of 13 sampled residents(Residents #44, #5, #24, #9, #14 and #28). The census was 46. Review of the facility's Side Rails policy, dated 10/17/23, showed: -Policy: Assess resident side rail restraint needs on admission, annually and with any significant change in order to ensure the resident's highest practicable physical and psychosocial well-being. Review quarterly; -Procedure: -Nursing staff will assess need for side rails at time of admission, annually and with any significant change and place in the chart, reviewing quarterly; -Side rails will be evaluated quarterly and reduced/eliminated as possible. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and offer nourishing snacks at bedtime. This affected all residents who ate at the facility. The census was 46. Review of the dietary records, showed mealtimes scheduled for the following: -Breakfast meal at 7:30 A.M.; -Lunch meal at 12:15 P.M.; -Dinner meal at 5:30 P.M. During a group interview on 5/13/25 at 11:00 A.M., six residents, whom the facility identified as alert and oriented, attended the group meeting. The residents said the staff just started passing out snacks. They pass the snacks out during the day, but not after dinner. This started within the last week or two. During an interview on 5/14/25 at 12:33 P.M., Certified Nursing Assistant (CNA) B said he/she worked the evening shift and snacks were not passed out in the evening. Activities would pass out snacks after lunch. [...]

Inspectors wroteBased on observation and interview, the facility failed ensure the ice machine had an air gap to prevent backflow from the drain pipe into the ice machine, potentially contaminating the contents of the ice machine. The census was 46. Observations on 5/12/25 at 9:53 A.M., 5/13/25 at approximately 8:30 A.M. and 5/14/25 at 8:07 A.M., 10:22 A.M. and 11:32 A.M., showed the ice machine located in the kitchen. The ice machine drain tubing extended down from the ice machine with the lower end of the drain tubing directly in the drain pipe. During an interview on 5/14/25 at 11:50 A.M., the Dietary Manager said he was not aware if there was an air gap from the drain tubing and drain pipe of the ice machine. When shown the tubing and drain, he said he would have to ask the Maintenance Director. During an interview on 5/14/25 at 11:53 A.M., the Maintenance Director said there was no air gap. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS), for two residents who required EBP for wound treatment or a medically inserted device (urinary catheter, a sterile tube inserted into the bladder through the urinary tract to drain urine) (Residents #14 and #20). In addition, staff failed to cleanse the shared blood sugar machine (Accu-check) with approved cleansing products between each resident use. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their antibiotic stewardship policy by failing to collect data regarding residents' antibiotic treatments and reviewing and documenting that data on the facility approved antibiotic surveillance tracking form. This deficient practice had the potential to affect all residents receiving antibiotics. The census was 46. Review of the facility's Antibiotic Use Stewardship policy, dated 9/2/18, showed: -Policy Statement: To develop on going best practices to improve antibiotic use; -Policy: Antibiotic prescribing will be monitored & tracked monthly utilizing best practice standards developed by the Centers for Disease Control and Prevention (CDC) and other professionals; -Procedure: -Director of Nursing (DON)/designee will track dose, duration & indication of antibiotics prescribed monthly; [...]

Inspectors wroteBased on interview, the facility failed to designate one or more individuals with specialized training in infection prevention and control as the Infection Control Preventionist (ICP) for the facility's infection prevention control program. The census was 46. During the entrance conference on 5/12/25 at 9:14 A.M., the Administrator said the facility did not have an ICP. During an interview on 5/14/25 at 2:51 P.M., the Director of Nursing (DON) said the Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) Coordinator was in the process of getting her ICP certification. The DON just started her ICP classes for certification as well. During an interview 5/15/25 at 12:19 P.M., the Administrator said she expected the facility to have a certified ICP.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete an inspection of bed frames, mattresses and side rails as part of a regular maintenance program to identify areas of possible entrapment for six residents (Residents #44, #5, #24, #9, #14 and #28) of 13 sampled residents with side rails. The census was 46. Review of the facility's Side Rails policy, dated 10/17/23, showed: -Policy: Assess resident side rail restraint needs on admission, annually and with any significant change in order to ensure the resident's highest practicable physical and psychosocial well-being. Review quarterly; -Procedure: -Side rails will be evaluated quarterly and reduced/eliminated as possible. 1. Review of Resident #44's hand written Bed Rail/Assist Bar Evaluation, showed one completed on 9/17, but did not specify the year. A half length and quarter length rail was indicated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they had a system in place to track the required Certified Nurse Aide (CNA) 12 hours annual education (in-services). The facility identified 18 CNAs who worked for the facility for at least one year. Two Certified Medication Technicians (CMTs), (CMT L and CMT K) and eight CNAs (CNA J, CNA I, CNA M, CNA N, CNA O, CNA P, CNA Q, and CNA R), were sampled. The facility failed to document the date and length of time the training was provided for 10 of 10 sampled staff. The census was 46. 1. Review of CMT L's employee file, showed: -Date of hire: 9/8/22; -Evaluation date: 9/8/24, in the date column, 21 topics were checked; -The in-service failed to show the date and length of time the training was provided. 2. Review of CMT K's employee file, showed: -Date of hire: 1/9/24; -Evaluation date: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation, for one resident (Resident #48). The sample was 13. The census was 46. Review of the facility's Discharge Summary and Plan policy, reviewed 2/21, showed: -The discharge plan, instructions and summary provides a recapitulation or summary of the resident's stay; -Discharge planning will begin upon admission to the facility; -Admitting nurse will document the resident, family/caregiver stated reason for admission and the resident, family/caregiver plan for discharge; -Case Manager or Minimum Data Set (MDS, a federally mandated assessment completed by facility staff) nurse will make post discharge follow up calls and complete the discharge post discharge, follow up phone call assessment in the resident record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess one resident for the use of a belt restraint (Resident #44). The resident had a belt restraint on his/her wheelchair. The facility failed to assess the resident for its use, obtain a physician's order and document the use in the resident's care plan. In addition, the facility failed to ensure staff accurately documented medications, treatments, pain assessments, and behavior monitoring for two residents (Residents #19 and #6). The sample size was 13. The census was 46. Review of the facility's Restraints policy, dated 9/2/29, showed: -Policy Statement: Restraints are devices that prevent or restrict certain actions and/or behaviors and are not easily removed. There are Federal Regulations that govern the use of restraints on residents in long-term care facilities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care consistent with professional standards of practice when staff failed to transcribe a new order, resulting in the treatment not administered for one resident (Resident #24). The sample was 13. The census was 46. Review of the facility's Medical Provider Orders policy, dated reviewed/revised 4/17/22, showed: -If using electronic medication records, input the medication and/or treatment order according to the electronic health record (EHR) instructions and facility policy; -When a new order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order; -Validate the new order in the electronic Medication Administration Record (MAR)/Treatment Administration Record (TAR); [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an environment free of accident hazards by not maintaining water temperatures in resident rooms on the 100 hall and in the unlocked and accessible staff break room, between 105 degrees Fahrenheit (F) and 120 degrees F. This affected five sampled resident rooms, which included Resident #5. The temperatures at the sinks measured as high as 143 F. The sample size was 13. The census was 46. 1. Observations on 5/12/25 of the unlocked accessible employee break room handwashing sink, showed: -At 10:35 A.M., the water measured 137.8 F.; -At 11:50 A.M., the water measured 143 F.; -At 2:20 P.M., the water measured 139.0 F. Review of the facility's temperature logs, showed no documentation of temperatures for the employee break room. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy when staff failed to ensure one resident's dialysis (a procedure that cleanses the blood of its impurities) communication logs were completed for all appointments (Resident #42). The facility identified one resident who received dialysis services. The sample was 13. The census was 46. Review of the facility's Dialysis Communication policy, dated 2/21, showed: -Director of Nursing (DON) or designee will contact dialysis unit to establish the communication, explain the facility will be sending a communication form that will facilitate the sharing of resident information surrounding dialysis; -A dialysis communication form will be used to send information to and from the facility to the dialysis center and back; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had access to mail delivered on the weekend. This had the potential to affect all residents at the facility. The census was 46. Review of the facility's Residents' Right policy, revised December 2016, showed: -Policy Statement: -Employees shall treat all residents with kindness, respect, and dignity; -Policy Interpretation and Implementation: -Federal and state laws guarantee basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness, and dignity; -Communication with and access to people and services, both inside and outside the facility; -Exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; -Be supported by the facility in exercising his or her rights; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice when one resident (Resident #3) had a significant increase in pain identified on 12/18/24 and had to wait over 12 hours for an x-ray order to be obtained. The x-ray completed on 12/19/24 showed the resident had a right hip fracture and the resident was sent to the hospital for further evaluation and treatment. The sample was 6. The census was 48. Review of the facility's Change in Condition Nursing Intervention policy, dated 2/18/16 and revised 9/19/19, showed: -Policy Statement: Because of the age and condition of residents in a nursing home, they are subject to many changes in condition. Changes in condition require assessment and documentation by a licensed nurse; -Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided meet professional standards of practice when a facility nurse pre-pulled medications for residents, documented the medications as administered, and never administered the medications. This resulted in nine residents not receiving their ordered medications (Residents #4, #5, #11, #7, #9, #8, #10, #1 and #12). The census was 44. The sample was 14. The administrator was notified on 6/21/24, of the past non-compliance. The facility educated staff of the requirement to administer medications at the time they are pulled and that only the staff person who pulls the medications are allowed to administer the medication. The facility conducted an investigation to determine which residents were affected and are monitoring ongoing compliance. The deficiency was corrected on 6/10/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's right to be free from physical abuse was not violated (Resident #1) when a resident (Resident #2) punched the resident in the back of the head with a closed fist three times. Resident #2 attempted to strike Resident #1 a fourth time but staff intervened and separated the residents. These two residents had an incident occur approximately one month ago, in which Resident #2 hit Resident #1 in the eye. This incident caused Resident #1 to have a laceration over his/her left eyebrow. The sample was 3. The census was 47. Review of the facility's undated Abuse, Prevention and Prohibition policy, showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #2), diagnosed as having dementia with behavioral disturbance and exhibiting increased symptoms/behaviors such as striking the same resident (Resident #1) in the head twice on two separate occasions (3/4/24 and 4/24/24), received the appropriate treatment and services to attain or maintain his/her highest practicable physical, mental and psychosocial well-being, by failing to implement an ordered psychiatric consult or update the resident's care plan until after the second incident. The first incident caused a laceration above Resident #1's left eyebrow. The sample size was 3. The census was 47. Review of Resident #2's hospital records, prior to the facility admission, dated 9/26/23, showed: Patient is presenting with concern for self neglect and possible injury to himself/herself with firearm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's rights to be free from physical abuse was not violated (Resident #1) when a resident (Resident #2) hit the other resident in the eye. This resulted in a laceration. The census was 45. The sample was 3. The Director of Nursing (DON) was notified on 3/08/24, of the past non-compliance. The facility immediately took steps to protect the resident and set interventions in place to prevent further abuse. Staff were in-serviced on resident safety. The deficiency was corrected on 3/4/24. Review of the facility's undated Abuse, Prevention and Prohibition policy, showed: -Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities, three errors occurred, resulting in a 12% error rate (Residents #44, #254, and #30). In addition, the facility failed to have a policy to address when medications are due based on the codes entered into the medical record. The census was 49. 1. Review of the facility's Medication Administration policy, dated [DATE], showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the medical provider and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the medication administration record to identify medications to be administered; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were discarded according to the expiration date for one of two medication carts reviewed with expired medicine that remained in the cart. This resulted in one resident being administered expired insulin (Resident #44). In addition, the facility failed to permit only authorized personnel to have access to the keys to the medication room. The facility identified having one medication room and four medication/treatment carts. The census was 49. Review of the facility's Labeling of Medications and Biologicals policy, dated 9/1/21, showed: -All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications; -Medication labels must be legible at all times. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of the residents by failing to ensure the quality of the labs obtained. The facility failed to follow manufactures directions for blood glucose (sugar) test strips to ensure accurate results. Improperly stored test strips were used to check residents' blood sugar levels (Resident #7, #1, #25, and #44). The census was 49. Review of the facility's Centers for Medicare and Medicaid Services (CMS) Clinical Laboratory Improvement Amendments (CLIA) certification of waiver, effective 9/1/22 and expiration 8/31/24, showed: -Laboratory name and address, listed the facility name and address; -The above named laboratory located at the address shown hereon may accept human specimens for the purpose of performing laboratory examinations or procedures. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident only self-administered medications after the interdisciplinary team had determined which medications may be self-administered, for one of one resident observed to have medications left at the bedside for later self-administration, for two of three days of survey. The sample was 13. The census was 49. Review of the facility's Resident Self-Administration of Medication policy, dated 9/1/21, showed: -It is the policy of this facility to support each resident's right to self-administer medications. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely; -The results of the interdisciplinary team assessment is placed in the resident's medical record; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper transfer techniques were utilized in the transfer of dependent residents. This failure occurred in one of one stand-by assist transfers observed, for one resident (Resident #13). The sample size was 13. The facility census was 49. Review of the facility's Transfer Techniques Policy, revised 4/17/19, showed: -The use of appropriate devices (lifts, gait belts, draw sheets, etc.) to provide a safe means of lifting or transferring residents, when used properly, protect both the resident and the employee from injury; -In order to prevent injury to staff or residents, employees shall use appropriate devices to transfer/ambulate/reposition residents; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a significant medication error when staff administered expired insulin to a resident (Resident #44). The census was 49. Review of the facility's Medication Administration policy, dated [DATE], showed: -Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the medical provider and in accordance with professional standards of practice, in a manner to prevent contamination or infection; -Review the medication administration record to identify medications to be administered; -Identify expiration date. If expired, notify the nurse manager; -Administer medications as ordered in accordance with manufacturer specifications; -Sign the medication administration record after administration. Review of Resident #44's medical record, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. The facility posted the survey results in the library on the top shelf, out of reach of residents or visitor who require the use of a wheelchair. The census was 49. Review of a sign, posted near the front entrance, showed survey results available for review in activities, social services, and the facility library. Observation on 12/12/23 at 9:32 A.M., showed the survey binder located in the library, approximately 6.5 to 7 feet up the air, on a bookshelf. At 9:40 A.M., the Social Worker pointed out a survey binder located in her office on a bookshelf, behind her desk. She said her office is locked when she is not in the building. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain laboratory services to meet the needs of the residents by failing to ensure the quality of the labs obtained when they failed to meet the applicable requirements for obtaining their own labs. The facility failed to follow manufactures directions for quality control check of the blood glucose (sugar) test machines to ensure accurate results. The census was 51. Review of the quality control solution for the blood glucose machine manufacturer's directions, also provided by the facility as the policy for completing quality control checks, titled Performing a Control Solution Test, showed: -You should check your meter and test strips using Assure Prism Control Solution. The control solution ranges are printed on the labels. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment, reflective of the resident's status at the time of the assessment for one resident who had wounds at the time of the assessment (Resident #9) and for five of five residents investigated for hospice who had a life expectancy of less than six months (Residents #5, #12, #16, #14 and #34). The facility identified 12 residents as receiving hospice services. The sample was 13. The census was 51. 1. Review of Resident #9's admission wound assessment, dated 6/17/21, showed a left lower leg stasis ulcer (breakdown of the skin caused by fluid build-up from poor vein function) was present on admission and measured 13 centimeters (cm) in length, 11 cm wide, and 0.3 cm deep. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis services received meet professional standards of practice for one resident who received dialysis services (Resident #17). The facility failed to ensure staff completed post dialysis assessments per their policy and acceptable standards of practice. The facility identified as only having one resident on dialysis services. The census was 51. Review of the facility's Dialysis Resident Care policy, dated 10/14/18, showed: -Policy statement: To maintain best clinical practices for shunt (dialysis access site) care and resident's receiving dialysis; -Policy: To monitor and educate staff and residents about good post-dialysis care; -Procedure included: -Assess residents upon return from dialysis treatment and document in nurse's notes: -Monitor blood pressure, report low or high blood pressure; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were not kept past their expiration date and that medications for residents who were no longer in the facility were removed from the active medication supply for one of one medication room, one of one medication cart and one of one treatment cart observed. In addition, the facility failed to store all drugs and biologicals in locked compartments and controlled substances behind two locked compartments when the medication room door was left propped open with no staff present and as a resident walked independently past the door (Resident #15). The facility identified having one medication room, three medication carts and one treatment cart. The census was 51. Review of the facility's Medication Storage in the Facility policy, dated June 1, 2018, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide palatable food and serve what was listed on the menu for one resident (Resident #5) out of six residents who received a pureed diet. The facility also failed to follow the recipes for pureed diets and provide the amount of food specified on the menu. The census was 51. 1. Review of Resident #5's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/7/21, showed: Severe cognitive impairment; -Total dependence on staff for bed mobility, transfers, dressing, personal hygiene and eating; -Diagnoses included: Cachexia (general weight loss occurring during course of chronic disease), progressive neurological condition, high blood pressure, high cholesterol, non-Alzheimer's dementia and anxiety disorder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date food when it was removed out of the original container. The census was 51. Review of the facility's policy dated 8/12/18, regarding Food Safety Storage Labeling and Dating, showed: -Foods will be properly stored, labeled and dated according to current practice standards; -All items must be dated when received and not kept longer than three days after receipt; -Items past the safe use by date will be discarded; -Administrator will check in dietary and nursing refrigerators at least weekly. Observation on 9/22/21 at 9:26 A.M. and showed the following -In the freezer, three bags hash browns not dated and taken out of the original box; -In the freezer, four bags of spinach not dated and taken out of the original box; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the transmission of infections. Staff failed to follow proper hand hygiene and infection control procedures for four of four perineal (the area to include the buttocks and the genitals) care observations (Residents #19, #5, #29 and #42). Staff failed to perform proper hand hygiene before adjusting or assisting a resident with their face mask (Resident #10). Staff touched a resident's sandwich with bare hands. Staff failed to properly sanitize a shared Hoyer lift (mechanical lift) before and/or after use (Resident #36). Staff used resident personal care items to turn on and off the water prior to using them on the resident (Resident #2). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect residents' personal privacy during personal care. One resident was left naked and exposed while staff allowed housekeeping into the room to clean (Resident #19). In addition, staff failed to ensure a resident was not visible from the hallway when partially dressed while staff were present and that the resident was not visible to the roommate during incontinence care (Resident #5). This affected two of four residents observed during incontinence care. The census was 51. Review of the facility's admission packet, provided to residents upon admission to the facility, showed Know Your Rights: You have the right to privacy in medical treatment and personal care. You should be treated with consideration and respect, with full recognition of your dignity and individuality. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of two mechanical lift transfers one of three stand by transfers observed (Residents #2 and #29). The census was 51. Review of the facility's Transfer Techniques policy, dated 4/17/19, showed: -Policy statement: Use of appropriate devices (lifts, belts, draw sheets, etc.) provide a safe means of lifting or transferring residents and, when used properly, protect both the resident and the employee from injury; -Lifts: Use for totally dependent residents or anyone with contractures (tightening of the tendons and joints resulting loss in range of motion), amputations, obesity, etc. Do not attempt to use the lift unless you have been trained and feel comfortable with the procedures. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are free from any significant medication errors, for one resident (Resident #16) who was administered expired insulin. The census was 51. Review of the facility's Medication Storage in the Facility policy, dated [DATE], showed outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. Review of Resident #16's electronic medical record, showed: [...]