Robert Lee Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #31) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #31's behaviors. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #3) reviewed for transfers in that: NA A and CNA B failed to safely transfer Resident #3 with a gait belt. CNA C and CNA D failed to demonstrate the skills to safely transfer the DON. These failures could place residents at risk for injuries due to not receiving the appropriate level of assistance to prevent accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 (Resident #3) of 4 residents reviewed for competent nursing staff, in that: NA A and CNA B failed to safely transfer Resident #3 with a gait belt. CNA C and CNA D failed to demonstrate the skills to safely transfer the DON using a gait belt. These failures could place residents at risk for injuries due to not receiving the appropriate level of assistance to prevent accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's one of one kitchen. The facility failed to ensure: Food debris was not on the floor in the freezer. Staff did not transport dishes by holding them against their body. Staff completed hand hygiene appropriately. Dishes were stored in a manner to prevent contamination. Prevention of contamination of salad bar containers by staff handling practices. Frozen meat was stored in a manner to prevent contamination in the event of thawing. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #24) reviewed for care plans in that: Resident #24 did not have a care plan addressing the use of her ankle splint. This failure could affect resident by placing her at risk of not receiving individualized care and services to meet her needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents reviewed for quality of care. (Resident #24) The facility did not assess, obtain orders or monitor Resident #24's ankle splint. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #19) of 6 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was on Resident #19's doorway. This failure could place residents at risk of not receiving appropriate respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily information that included the facility name, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 2 days (09/25/2024 to 09/26/2024) of 3 days observed for staff posting. The facility failed to post the daily staffing information for 09/25/2024 and 09/26/2024. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident status for 1 of 12 residents (Resident #3) whose MDS assessments were reviewed, in that: Resident #3's MDS assessment dated [DATE] was coded as not being PASRR positive when the resident was positive. This failure could affect residents in the facility and put them at risk of inadequate care based on inaccurate assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents, for 1 of 2 Medication Carts and 1 of 2 Treatment Carts reviewed for pharmacy services. - The facility failed to ensure the Medication Cart did not include the following expired medications: Eszopiclone 1 mg tablets, Olmesartan Medoxomil 40mg tablets, Aspirin 81mg, and Carboxymethylcellulose Sodium 0.5% lubricating eye drops. These failures could place residents at risk of receiving expired medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in locked compartments , for 1 of 2 Medication Carts and 1 of 2 Treatment Carts reviewed for pharmacy services. - The facility failed to ensure the Medication Cart did not include the following medications found loose in the medication drawer: Gabapentin 100mg x 2 capsules, Namenda 10 mg x 1 tablet, Buspar 15 mg x 1 tablet and Buspar 5mg x 1 tablet. - The Treatment Cart was unlocked and had Insulin, Oral Glucose, syringes, and lancets. These failures could place residents at risk of receiving expired medications.