Lenox Care Center

Inspectors wroteBased on observations, staff interviews, kitchen cleaning checklist and policy review the facility failed to maintain clean and sanitary conditions in the kitchen, failed to label and store food items and discard leftovers after 3 days in order to maintain food quality and reduce the risk of food-borne illness in the kitchen for two of two kitchen observations. The facility staff also failed to conceal hair completely in a hairnet for two of two meal service observations. The facility reported a census of 25 residents.

Inspectors wroteBased on record review, observations, staff interview and policy review the facility failed to utilize enhanced barrier precautions (EBP's) and failed to ensure staff followed infection control practices to protect against cross contamination and potential spread of infection for 2 of 4 residents sampled on EBP's (Resident #1 and #22). The facility staff also failed to use a barrier and utilize appropriate wound care techniques, and failed to handle soiled linens to prevent the potential spread of infection for 1 of 3 residents observed for wound care (Resident #22). The facility also failed to develop a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility reported a census of 25 residents.

Inspectors wroteBased on record review, observation, resident and staff interview, policy review and the National Fire Protection Association (NFPA), the facility failed to ensure that oxygen was not in the vicinity of residents that were smoking for 1 of 1 resident observed with oxygen in use (Resident #13). The facility reported a census of 25.

Inspectors wroteBased on clinical record reviews, staff interview, and policy review, the facility failed to identify and consistently document non-pharmacologic behavior interventions for 3 of 3 residents (#3, #6, #7) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 25 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to identify an expired medication before it was administered to 1 of 4 residents (#17). The facility reported a census of 25 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, resident interview, staff interview, and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed follow physician ordered interventions for a resident with no bowel movement for 3 days and 5 days for 2 of 3 residents reviewed (Residents #2 and #3). The facility reported a census of 25 residents.

Inspectors wroteBased on observation, policy review, and staff interview the facility failed to provide appropriate infection prevention practices when providing care to a resident with a catheter, that was on Enhanced Barrier Precautions (EBP) for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 25 residents.

Inspectors wroteBased on the clinical record review, resident interview, staff interview and policy review the facility failed to provide access to personal funds managed by the facility for 1 of 1 residents reviewed. The facility reported a census of 24 residents.

Inspectors wroteBased on observation, document review and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the residents by not serving residents on a mechanical soft diet the appropriate amount of meat according to the menu for 4 of 24 residents reviewed. The facility reported a census of 24 residents.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to provide food at an appetizing temperature when the mechanical soft meatballs temperature was 95 degrees in the steam table. The facility reported a census of 24 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store food in accordance with professional standards by not labeling and dating open food items and discarding leftovers. The facility also failed to sanitize a thermometer prior to use. The facility reported a census of 24 residents.

Inspectors wroteBased on facility document review, family interview, staff interviews, personnel file review and policy review, the facility staff failed to report suspected abuse between a staff member and a resident (#15) within two (2) hours after the observed behavior. The facility reported a census of 24.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to develop and implement a Comprehensive Care Plan for 2 of 12 residents (Resident #16, and #5) reviewed. The facility reported a census of 24 residents. 1. The Minimum Data Set (MDS) for Resident #16 dated 1/28/25 identified a Brief Interview for Mental Status (BIMS) score of 2/15 indicating a severe cognitive impairment. The MDS included diagnoses of Non-Alzheimer's Dementia, depression, psychotic disorder, and hypertension. The MDS did not identify a diagnosis for use of oxygen. The MDS indicated Resident #16 did not utilize oxygen during the reporting period. The Electronic Medical Record (EMR) Physician Orders dated 2/25/25 revealed Resident #16 was ordered on 11/20/22 oxygen at 2 liters/minute via nasal cannula as needed to keep saturations above 90%. [...]

Inspectors wroteBased on clinical record review, staff interviews, observations and policy reviews the facility failed to review and revise the Care Plan interventions for 3 of 12 residents reviewed (Resident #12, #19, and #2). The facility failed to revise Care Plan Interventions for a resident who smoked, a resident who utilized a power wheelchair (w/c), and failed to include a family representative in the Care Plan Conference. The facility reported a census of 24 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, staff interviews, and policy review the facility failed to provide an opportunity for bath or shower and reposition 1 of 12 residents reviewed (Resident #5). The facility reported a census of 24 residents.

Inspectors wroteBased on Electronic Health Records (EHR), staff interview, and policy review the facility failed to provide restorative cares to promote range of motion to 1 out of 1 residents reviewed (Residents #5). The facility reported a census of 24 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 1 resident (#1) reviewed for nutrition. This failure resulted in Resident #1 experiencing a weight loss of 11.05% in 6 months. The facility reported a census of 24 residents.

Inspectors wroteBased on observations, record review, staff interview, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 28 opportunities for errors resulting in an error rate of 7.14% (Residents #178). The facility identified a census of 24 residents.

Inspectors wroteBased on observation, Electronic Health Record (EHR) review, policy review, and staff interview the facility failed to provide appropriate infection prevention practices by not completing appropriate hand hygiene when personal care was completed for 1 of 3 residents reviewed (Resident #5). The facility reported a census of 24 residents.

Inspectors wroteBased on observations, resident interviews, clinical record review, facility record review and staff interviews the facility failed to provide activities to meet the interests, and the physical, mental, and psychosocial well-being of the residents for 3 of 3 reviewed (Resident #7, #10 and #11). The facility reported a census of 17 residents.

Inspectors wroteBased on observations, resident interviews, staff interviews, and policy review the facility failed to prepare and serve food in accordance with appropriate temperatures. The facility reported a census of 17 residents.

Inspectors wroteBased on observations, staff interviews, clinical record review, and facility policy review the facility failed to provide dignity by leaving a catheter bag uncovered and easily visible from the hallway for 1 of 1 resident reviewed (Resident #4). The facility reported a census of 17 residents. Findings Include: The Minimum Data Set Assessment (MDS) dated [DATE] documented Resident #4 did not have a Brief Interview for Mental Status completed due to rarely/never understood, and indicated impairment with short-term and long-term memory, memory/recall ability, and moderately impaired cognitive skills for daily decision making. The MDS documented an indwelling catheter, and diagnosis of neurogenic bladder, retention of urine, and Lennox-Gastaut Syndrome, intractable without status epilepticus. [...]

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to complete an assessment on a resident who had fallen prior to moving the resident with a mechanical lift from the floor for 1 of 1 residents (Resident #170) reviewed. The facility reported a census of 17 residents.

Inspectors wroteBased on clinical record review, observation, therapy discharge notes, staff interview and facility policy, the facility failed to provide 1 of 1 residents (Resident #12) reviewed with an individualized Restorative Program in order to prevent a further reduction in range of motion and optimize skin integrity and minimize pain during cares. The facility reported a census of 17.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to provide appropriate incontinence care for one (Resident #13) of three residents reviewed. The facility reported a census of 17 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review the facility failed to properly label enteral feeding bottles and water bags prior to beginning a feeding for 1 of 1 residents (Resident #4) reviewed. The facility reported a census of 17 residents.

Inspectors wroteBased on observations, staff interviews, and policy reviews the facility failed to prepare, serve, distribute, and store food in accordance with professional standards. The facility reported a census of 17 residents.

Inspectors wroteBased on observations, clinical record review, policy review, and staff interview the facility failed to complete proper hand hygiene between assisting residents to dine, after completing incontinence care for one of three residents reviewed (Resident #13) and failed to apply a glove before touching popcorn provided to a resident to maintain standard precaution for infection control. The facility reported a census of 17 residents.