Letcher Manor

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to provide medications in a timely manner to treat a Urinary Tract Infection (UTI) for 1of 38 sampled residents, Resident (R)117. R117 developed a UTI and Fosfomycin 3 grams as a single-dose treatment (antibiotic) was ordered on 11/11/2026 at 11:28 AM. However, the medication was not administered until 11/15/2025 at 4:23 PM, 4 days later. The resident experienced pain and discomfort.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, the facility failed to electronically transmit the discharge assessment within 14 days as required for 1 of 31 sampled residents, (Resident (R)82). R82 was discharged on 10/07/2024; however, the resident's Discharge Minimum Data Set (MDS) Assessment was not transmitted as of 02/27/2025.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop and/or implement a comprehensive person-centered care plan to meet the needs of 1 of 31 sampled residents, (Resident (R) 88). R88 was noted to have numerous refusals of wound care; however, the facility failed to develop the resident's comprehensive care plan to address her refusals

Inspectors wroteBased on observation, interview, and review of the facility's policy, it was determined the facility failed to prepare and serve food in a sanitary manner and in accordance with professional standards for food service safety. Observation of a test tray on 02/25/2025, with the Dietary Manager (DM) and Dietary Aide (DA) 1 revealed hot food temperatures (temps) were below 130 degrees Fahrenheit (F), and cold food items were above 41 degrees F. The failure had the potential to affect all residents of the facility who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 31 sampled residents, (Resident (R)37, R95, R100, and R113).

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to provide adequate supervision and assistance devices to ensure the safety of its residents for 1 of 31 sampled residents (Resident (R)39). The facility allowed R39 to roam freely into other residents' hallways and rooms without providing adequate supervision of the resident to ensure the safety and well-being of all residents.

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents were free from misappropriation of property. Controlled substances/medications were misappropriated without authorization from eight (Resident (R) 4, R10, R11, R13, R45, R78, R86 and R90) of 89 sampled residents.

Inspectors wroteBased on observation, interview, record review, manufacturer ' s recommendations, and review of the facility's policy, it was determined the facility failed to ensure it was free of a medication error rate of five percent or greater. During the medication pass observation of 69 opportunities for administration of medication, there were nine opportunities in which medications were not administered according to manufacturer ' s recommendations and/or the facility ' s medication policy, resulting in an error rate of 13.04%. The failure affected two (Resident (R) 25 and R113) of 19 sampled residents. R25 ' s insulin injection was not prepared correctly and R113 failed to receive the full value of eight crushed medications.

Inspectors wroteBased on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to develop and implement a person-centered comprehensive care plan for three (3) of twenty-nine (29) sampled residents (Resident #68 and Resident #94 related to respiratory care (oxygen therapy), and Resident #110 related to range of motion). Review of the comprehensive person-centered care plan for Resident #68 and Resident #94 revealed the person-centered comprehensive care plan did not address actual liter flow of the oxygen nor the route of the oxygen to be administered to the resident for Resident #68 and the actual liter flow for Resident #94. In addition, the facility failed to specifically address the limitations in range of motion (ROM) to Resident #110's hands and plan interventions to prevent further declines in ROM.

Inspectors wroteBased on observation, interview, and resident record review it was determined the facility failed to accurately complete an assessment for one (1) of twenty-nine (29) sampled residents (Resident #110) related to the resident's range of motion. Resident #110 was determined to have limited range of motion (ROM) to bilateral hands; however, the facility failed to identify/assess the limitations in range of motion to the resident's hands.

Inspectors wroteBased on interview, record review, and facility policy review it was determined the facility failed to ensure the discharge summary included a recapitulation of the resident's stay that included pertinent information regarding the resident's course of illness/treatment or therapy, and pertinent radiology and consultation results for one (1) of two (2) closed records reviewed (Resident #115).

Inspectors wroteBased on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to ensure two (2) of twenty-nine (29) sampled residents (Resident #68 and Resident #94) who were provided respiratory care (oxygen therapy) received care according to the person-centered comprehensive care plan. Review of the comprehensive person-centered care plan for Resident #68 and Resident #94 revealed the residents had an intervention for the facility to provide oxygen as ordered by the physician. However, the person-centered comprehensive care plan did not address actual liter flow of the oxygen nor the route of the oxygen to be administered to the resident.