Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lee Healthcare during CMS and state inspections, most recent first.
A resident with moderate vascular dementia, mood disturbance, and a history of agitation had a care plan calling for identification of triggers and use of de-escalation strategies. While the resident was seated at the nurses’ station, a CNA briefly touched the resident’s hat, and the resident immediately yelled and objected, causing that CNA to stop. Another CNA, despite witnessing this clear objection, then touched the hat, and after the resident loudly demanded that the CNA stop, touched it a second time. This taunting behavior provoked escalating agitation, with the resident becoming verbally abusive and physically destructive toward facility property, demonstrating a failure to treat the resident with dignity and to respect personal possessions.
A resident with a femur fracture and bilateral foot drop was seen by the MD for right heel pain and discoloration concerning for a developing pressure injury. The MD recommended offloading the heel, wound care follow-up, and discussed the visit with nursing, but the TAR and chart lacked documentation that nursing entered or carried out the offloading intervention. The nurse on duty could not recall the discussion, and the ADON said the recommendation should have been entered as an order so staff would be aware and sign off completion.
A resident with DM, PVD, and a prior BKA had left toe ulcers that were not assessed and documented timely after podiatry identified infection signs and recommended cultures, x-ray, daily dressings, ABX, and wound care follow-up. The wound care consult was delayed, bone exposure and suspected osteomyelitis were not addressed promptly, and the resident later required hospital transfer, IV ABX, and amputation of the left great and second toes. After return, the facility did not accurately carry out the hospital’s NPWT and left shin wound orders, and the resident was observed with undated dressings and open areas.
A resident with diabetes, PVD, and a BKA had diabetic toe ulcers and an open shin area, but wound care orders and skin monitoring were not consistently carried out or documented. Surveyors observed an uncovered draining shin wound, and the resident reported the foot dressing was not being changed as ordered. Review of records and interviews showed three nurses who provided the wound care had not all completed required wound care competencies on hire and/or annually, and the DON confirmed the competency timing was overdue or missing.
Failure to Complete Annual CNA Performance Reviews: The facility failed to complete annual performance reviews for five CNAs sampled. The DON was unable to locate or provide the required reviews for all five CNAs, and the Administrator stated that annual reviews are needed to assess performance, confirm knowledge of care tasks, provide feedback, and identify education needs.
A resident with CLL and HF, who was cognitively intact and had a MOLST indicating DNR, had a Physician order listing Full Code instead. Nurse and DON review confirmed the mismatch between the MOLST and the active order used by staff for resuscitation decisions.
Failure to Respond to Resident Grievances: A resident with dementia had three grievances filed by a family member that were not completed, tracked, or resolved. The grievance forms were left blank in key sections, and the DON/Administrator could not locate evidence that the concerns were followed up on or responded to as required by the facility grievance process.
Failure to provide transfer/discharge notices, bed hold info, and Ombudsman notification: Two residents were sent to the hospital, but the record lacked evidence that the resident/representative received the required notice, bed hold policy, appeal information, or that the receiving facility got the needed discharge summary details. The facility also could not find documentation that the Ombudsman was notified for either transfer.
Incomplete MDS Section F Interviews: Multiple residents had comprehensive MDS assessments that did not include required Resident or Staff Interviews for Preferences for Customary Routine and Activities. Several residents were cognitively intact or able to communicate, yet Section F was left blank, while others who could not participate also had no Staff Interview completed. An MDS nurse stated the facility had been without an Activities Director and that these interviews were not being completed as part of that role.
A resident with a suprapubic catheter and colostomy had no physician orders in place for how staff should provide care and services for either device. Although the care plan included some related interventions, the ADON said the information was not comprehensive and expected orders for ostomy cleansing, wafer changes, and suprapubic catheter cleaning and dressing changes. The resident reported self-managing both devices with supplies from home, and the DON stated the facility had no policy or protocol for suprapubic catheters or ostomies.
Smoking supervision and assessment failures: The facility failed to follow its smoking policy for two residents. One resident with diabetes, bilateral amputations, CKD, and wounds had a smoking evaluation showing supervised smoking was allowed, but no smoking care plan was in place and residents were observed waiting for smoke time without staff, exiting through a keypad door, and smoking in an unsupervised area with a lighter present. Another resident with paraplegia and a C5 SCI resumed smoking, but the resident was not identified on the smoking list and was observed smoking before a timely smoking assessment was completed.
The facility failed to ensure that pharmacist MRRs were timely reviewed by the attending MD and either implemented or declined for three residents. One resident with CHF, CKD, and a mood disorder had repeated MRRs for PRN pain medication clarification with no timely physician response; another resident with depression, Alzheimer's disease, delusions, and anxiety had a pharmacist recommendation to follow up on a GDR for Risperdal that was not documented as reviewed by the MD when issued; and a third resident with Parkinson's disease and bipolar disorder had blank provider response sections on pharmacist recommendations to reduce Eliquis dosing, despite later order changes.
Incomplete nutritional supplement orders and MAR documentation were found for two residents. One resident had Parkinson’s Disease and bipolar disorder with significant weight loss, and another resident had CLL and HF. Their House supplement orders did not specify the amount to be given, and the MARs did not document the amount administered or accepted. The DON and an RN confirmed that the orders should have included the supplement amount.
A resident receiving Hospice services had incomplete Hospice documentation readily available in the chart, with only a few Hospice records present. Staff reported that Hospice notes should be kept in a separate binder, but they were unsure where it was stored and later had to request additional Hospice progress notes from the Hospice provider. The DON and ADON were also unsure who was responsible for serving as the liaison with Hospice to ensure the records were maintained.
Failure to Hold Required Quarterly QAPI Meeting: The facility did not hold a scheduled quarterly QAPI meeting, even though attendance sheets showed one was planned. The Administrator confirmed that QAPI meetings are required at least quarterly and that the meeting was not held as required.
Failure to Monitor Prophylactic Antibiotic Use: A resident received Nitrofurantoin for prophylactic recurrent UTI treatment, but the chart lacked documentation supporting a UTI history or the reason for starting the antibiotic. The IP line listings did not show the antibiotic was being monitored or reviewed, and the IP stated prophylactic antibiotic use was not being tracked even though residents on antibiotics were expected to be on the line listing.
Failure to Offer and Document COVID-19 Vaccine Consent: A resident over age 65 was not up to date with the COVID-19 vaccine, but the immunization consent form was left blank and there was no record that the vaccine was offered or declined. Nursing staff and the ADON stated consents were to be completed at admission, and the ADON confirmed there was no immunization form in the record for the resident.
The facility failed to maintain sanitary conditions in two unit kitchenettes, with crumb-laden toasters presenting a fire risk. Observations showed crumbs in toasters, and interviews revealed uncertainty about cleaning responsibilities. The Director of Housekeeping and Food Service Director were unsure who should clean the toasters, while the Regional Nurse suggested kitchen staff should maintain them.
A facility failed to maintain a clean environment in a resident's room, where surveyors observed brown, dried drip marks on the wall and windowsill over several days. Despite cleaning policies requiring regular cleaning, these marks remained visible to the resident, who was lying in bed facing the wall. The Director of Housekeeping acknowledged the oversight, noting that the room was scheduled for a deep clean and that such issues should have been addressed during routine cleaning.
A facility failed to complete a PASRR Level I Screening before admitting a resident with SMI, including PTSD and a later diagnosis of Borderline Personality Disorder. The Social Worker responsible was unavailable, and no other staff were trained to conduct the screening, leading to a delay in appropriate care evaluation.
A resident's wound dressing was not properly monitored or documented, as staff failed to obtain a physician's order and did not conduct ongoing assessments. The dressing, applied to the resident's elbow, was left unchanged for an extended period, leading to potential risks. The facility's protocol for weekly skin observations was not followed, resulting in the dressing being overlooked.
A resident with Parkinson's Disease and a femur fracture was discharged without a complete discharge summary or proper communication with follow-up care providers. The facility failed to ensure a comprehensive discharge plan, including necessary VNA services, leading to a delay in post-discharge care. Interviews revealed a lack of coordination among staff, with incomplete evaluations from Therapy and Social Work departments.
A facility failed to create a Trauma Informed Care Plan for a resident with PTSD, despite recommendations from a Social Services Evaluation. The resident's Comprehensive Care Plan lacked documentation of such a plan, and the Social Worker confirmed that it should have been developed but was not.
A facility failed to ensure complete CNA documentation for a resident with significant weight loss and nutritional risk. Despite a care plan requiring meal intake monitoring, records for June and July showed incomplete documentation. Interviews revealed that CNAs were expected to document each shift, but this was not consistently done, impacting the Dietician's ability to adjust dietary needs.
A facility failed to issue a Notice of Medicare Non-Coverage and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage to a resident's guardian. The facility did not successfully contact the guardian or provide evidence of sending a certified letter, leaving the guardian uninformed about the end of Medicare Part A coverage and potential financial liabilities.
A facility failed to provide a written Notice of Transfer and Discharge to a resident and their representative when the resident was transferred to the hospital. The resident's medical record lacked documentation of the notice, and interviews with staff revealed confusion about responsibility for issuing the notice. The Infection Preventionist confirmed that no education had been provided to nursing staff regarding this requirement.
Failure to Respect Resident’s Personal Possessions and Dignity
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions. The facility’s policy on Resident Rights and Responsibilities, revised January 2024, requires employees to treat all residents with kindness, respect, and dignity. Resident #1, admitted in August 2023, had diagnoses including moderate vascular dementia with mood disturbance and an anxiety disorder. A Quarterly MDS dated 09/30/25 documented moderate cognitive impairment with a BIMS score of 9/15. The resident’s Mood and Behavioral Care Plan, reviewed 12/03/25, noted vascular dementia with mood disturbance and agitation, with a history of hitting, kicking, grabbing, spitting, screaming, or threatening others, and identified interventions such as assessing triggers for aggression or agitation and providing de-escalation strategies including a quiet environment and reassurance. On 12/20/25, an altercation occurred between Certified Nurse Aide (CNA) #1 and Resident #1 at the nurses’ station. According to the facility’s investigation report and staff interviews, Nurse #1 was on the phone addressing a medical emergency while Resident #1 sat in a wheelchair at the nurses’ station, with CNA #1 and CNA #2 nearby. CNA #2 leaned forward to speak with the resident and briefly touched the top of the resident’s hat. Resident #1 immediately yelled and verbally objected, stating that the hat should not be touched, and CNA #2 stopped touching the hat after the objection. Despite having witnessed this objection, CNA #1 then approached and touched the resident’s hat. Nurse #1 and CNA #2 reported that Resident #1 loudly objected to CNA #1 touching the hat, demanded that CNA #1 stop, and that CNA #1 nevertheless touched the hat a second time. Nurse #1 stated that after the second touch, the resident’s agitation escalated, leading him to separate CNA #1 from the resident. When Nurse #1 returned to the nurses’ station area about 15 minutes later, Resident #1 remained very agitated, cursing and kicking a medication cart. CNA #1 acknowledged in a telephone interview that she touched the resident’s hat despite having seen the resident loudly object to CNA #2 doing so. The Director of Social Services later observed that the resident was “a bit revved up,” consistent with behavioral presentations that occurred at times for this resident, and the DON confirmed that CNA #1 had teased and provoked the resident by touching the hat despite the resident’s objections.
Incomplete Documentation of Physician Heel Offloading Recommendation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one sampled resident when a physician evaluated the resident for right heel pain and noted discoloration to the heel that was concerning for a developing pressure injury. In the physician's 10/18/25 visit note, the physician recommended offloading force from the right heel, having a wound care specialist evaluate and follow the resident, and documented that the visit was discussed with nursing staff. The resident had been admitted in October 2024 with diagnoses including a non-displaced comminuted fracture of the left femur and left-sided and right-sided foot drop. Review of the resident's medical record, including the TAR, found no nursing documentation to support that the physician's recommendation to offload the right heel was implemented. During interview, the nurse on duty that day said he could not remember exactly what the physician discussed, stated that after physician visits nursing staff were expected to enter any orders into the computer, and did not recall entering a treatment order or care plan intervention to offload the heel. The ADON stated that nursing was responsible for entering the physician's recommendation into the computer as an order so all staff would be aware and could sign off that the intervention was completed, but the record contained no documentation showing the intervention was entered or followed up on.
Delayed wound assessment and incomplete post-hospital wound orders
Penalty
Summary
The facility failed to provide timely and appropriate skin and wound care for a resident with Type 2 diabetes, peripheral vascular disease, and a right below-knee amputation. The resident’s left foot was evaluated by a podiatrist who documented reddened, warm, discolored toes with diabetic ulcers on the great, second, and third toes, along with drainage, odor, and signs of infection. The podiatrist recommended wound cultures, an x-ray, daily dressings, antibiotic therapy, and wound care follow-up, but the record showed no documented evidence of the status or condition of the left toe wounds for a period after the wounds were identified. The wound care specialist did not evaluate the resident’s left great and second toes until 17 days after the podiatrist’s findings. At that evaluation, the left great toe had exposed bone, hypergranulation, callous peri-wound tissue, and drainage, and the left second toe also had hypergranulation and drainage. The wound care specialist recommended Dakin’s solution dressings, x-ray to evaluate bone involvement, lab work, wound cultures, and surgical and/or vascular consultation because osteomyelitis was suspected. The x-ray was not completed until several days later and showed suspected osteomyelitis. The resident was then transferred to the hospital, where MRI confirmed osteomyelitis and the resident received IV antibiotics and underwent amputation of the left great and second toes. The facility also failed to obtain and implement accurate post-hospital treatment orders. The hospital discharge summary included wound care instructions for the toe amputation sites, including NPWT at 125 mmHg continuous and specific dressing instructions until the NPWT system arrived, as well as treatment for open areas on the left shin. On return to the facility, the resident was observed with undated dressings, open and exposed amputation sites, and an open area on the left shin that was not covered. The clinical record showed treatment orders that did not reflect the hospital’s NPWT instructions, and there was no documented evidence that the ordered NPWT or left shin wound treatment had been obtained or implemented.
Nursing Competency Gaps in Wound Care
Penalty
Summary
The facility failed to ensure that three nurses who provided wound care to a resident with diabetic foot wounds had been evaluated on hire and/or annually for wound care competency. The resident had a history of type 2 diabetes, a right below-the-knee amputation, and peripheral vascular disease, and was identified as having diabetic ulcers on the left great toe, second toe, and third toe, with redness, edema, drainage, odor, and signs of infection noted by the consultant podiatrist. The facility assessment stated it had the capability to care for residents with skin ulcers, skin and soft tissue infections, and advanced wound care needs, and that staff training included nutrition and skin/wound care education. The resident’s physician orders included wound care and diabetic foot care instructions for the left foot, including cleansing, dressings, and daily monitoring for abnormalities. The September 2025 physician orders did not include treatment orders for open areas on the left shin, even though an open, dime-sized area with clear drainage was observed there during surveyor observation. The resident stated he or she was not aware of any treatment to the shin area and said the dressing to the left foot was supposed to be changed twice daily but had only been changed once since readmission. The Director of Nursing stated weekly skin checks should be completed and that the resident should have had weekly non-pressure ulcer evaluations after the wounds were identified, but the evaluation was not completed until 8/22/25. Review of the August and September 2025 treatment records showed that Nurses #2, #3, and #4 provided wound care and/or diabetic foot care for the resident. Interviews with facility leadership confirmed that a wound care competency could not be found for Nurse #2 since hire, and that Nurse #3’s wound care competency was due and had not been completed. The DON stated wound care competencies should be completed on hire and annually thereafter, and the Corporate Clinical Nurse said it was important for the competencies to be completed to ensure safe and effective wound care.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for five CNAs sampled, including CNA #1, CNA #2, CNA #4, CNA #5, and CNA #6. Review of the facility's CNA Active Employee Listing showed CNA #1 was hired 7/28/15, CNA #2 was hired 7/1/24, CNA #4 was hired 12/4/23, CNA #5 was hired 7/1/24, and CNA #6 was hired 2/5/24. During interviews, the DON stated that CNA performance reviews should be completed annually for all CNAs working in the facility, but she was unable to locate annual performance reviews for CNA #1 and CNA #2 and later could not provide annual performance reviews for CNA #4, CNA #5, and CNA #6. The Administrator also stated that annual performance reviews should be completed annually for all CNAs and said they were important to assess performance, confirm knowledge of care tasks, provide feedback, and identify education needs.
Advance Directive Orders Did Not Match MOLST
Penalty
Summary
Advance Directives were not honored for one resident when the facility failed to ensure that the Physician's orders accurately reflected the resident's wishes as documented on the MOLST form. The resident was admitted in July 2025 with diagnoses including Chronic Lymphocytic Leukemia and Heart Failure, and the MDS assessment indicated the resident was cognitively intact with a BIMS score of 13 out of 15. The MOLST form, completed and signed by the resident on 7/16/25, indicated a DNR preference. Despite the MOLST, the September 2025 Physician's Orders included an active order initiated on 7/23/25 for Advance Directive: Full Code. During review of the records, Nurse #4 stated that the Physician's Orders showed the resident as full code while the MOLST indicated DNR, and said this was a concern because the resident could be resuscitated when he/she did not desire resuscitation. The DON stated that the Physician's Order should match the MOLST form because staff would use that information to determine whether to resuscitate the resident if the resident's heart stopped.
Failure to Respond to Resident Grievances
Penalty
Summary
The facility failed to respond to or resolve grievances for one resident out of a sample of 26 residents. The deficiency involved Resident #54, who was admitted in March 2025 with a diagnosis that included dementia. Review of the facility policy titled Grievances showed that the administrator was responsible for oversight of the grievance process, including reviewing and tracking grievances, ensuring investigations were completed, and providing a response within seven working days of receipt. Review of the grievance binder showed three grievances filed by Family Member #1 on behalf of Resident #54 on 4/25/25. The grievance forms had blank sections for department notified and date, action taken, followed up, signature of the department head, and signature of the Executive Director and date. During interviews, Family Member #1 stated she had completed multiple grievances and sent multiple emails to the Administrator, but follow-up often occurred too late for staff to remember what had happened. The Administrator stated grievances were supposed to be routed to Social Work and then to the appropriate department for resolution, with the completed form returned for review and signature, but he could not locate evidence that the three grievances had been followed up on or responded to.
Failure to Provide Transfer/Discharge Notices, Bed Hold Information, and Ombudsman Notification
Penalty
Summary
The facility failed to ensure that a Notice of Transfer or Discharge and bed hold information were provided to residents or their resident representatives at the time of transfer or shortly thereafter, and failed to ensure the Office of the State Long-term Care Ombudsman was notified when residents were transferred to the hospital. The facility policy titled Transfer or Discharge Notice, revised 11/2024, stated that residents and/or representatives were to receive written notice of transfer or discharge, including the reason, effective date, appeal rights, bed hold policy, and Ombudsman contact information, and that a copy of the notice would be sent to the Ombudsman. Resident #74, admitted in July 2025 with diagnoses including Peripheral Vascular Disease, Type 2 DM with multiple diabetic leg and foot ulcers, and Atherosclerotic Heart Disease, was sent to the ED on 7/31/25 after the wound NP noted suspected deterioration of blood flow in the legs, increased pain, and that the resident was "not feeling well." The resident was admitted to the hospital, but the SW was unable to locate documentation that the Ombudsman had been notified. Resident #70, admitted in July 2025 with diagnoses including Type 2 DM, bilateral lower-extremity amputations, CKD, and wounds to the lower back and pelvis, was sent to the ED on 7/11/25 due to abnormal labs. The record contained no documented evidence that the resident/representative received the bed hold policy or notice of intent to transfer, that required information was provided to the receiving facility including a discharge summary with vital information, or that the Ombudsman was notified; the DON and Administrator also could not find evidence of the required documentation.
Incomplete MDS Section F Interviews
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately to reflect resident status for eight sampled residents. For Residents #1, #4, #6, #23, #48, and #67, the most recent comprehensive MDS assessments showed they were able to participate in a Resident Interview based on their BIMS scores, speech, and ability to make themselves understood, but Section F for Preferences for Customary Routine and Activities contained dashes for both the Resident Interview and Staff Interview, showing no interview was completed. Resident #1 had diagnoses including paraplegia, osteomyelitis, adult failure to thrive, and type 2 diabetes; Resident #4 had Huntington's Disease, PTSD, and bipolar disorder; Resident #6 had bipolar disorder, peripheral vascular disease, and CHF; Resident #23 had type 2 diabetes, repeated falls, and depressive disorder; Resident #48 had type 2 diabetes, spinal stenosis, and primary generalized osteoarthritis; and Resident #67 had CHF, peripheral vascular disease, and torsades de pointes. For Residents #3 and #31, the most recent comprehensive MDS assessments showed they were unable to speak or were rarely able to make themselves understood, had memory problems, and had severely impaired ability to make daily decisions. Despite this, Section F for Preferences for Customary Routine and Activities also contained dashes for the Staff Interview, indicating no Staff Interview was completed for these residents. Resident #3 had Huntington's Disease, and Resident #31 had Alzheimer's Disease with Early Onset, depressive disorder, and epilepsy. During an interview on 9/8/25 at 2:38 P.M., the MDS Nurse stated the facility had been without an Activities Director for some time and that the Resident and Staff Interviews for Section F were not being completed because it was part of the Activities Director job. She further stated that for Residents #1, #4, #6, #23, #48, and #67, a Resident Interview should have been attempted and, if unable to be completed, a Staff Interview should have been completed for the most recent comprehensive MDS assessment, but this was not done. She also stated that for Residents #3 and #31, a Staff Interview for Section F should have been completed for the most recent comprehensive MDS assessment, but this was not done.
Missing Orders and Policies for Catheter and Ostomy Care
Penalty
Summary
The facility failed to ensure staff followed professional standards of care and services for one resident with a suprapubic catheter and a colostomy. Resident #70 was admitted with diagnoses including type 2 diabetes, bilateral lower-extremity amputations, chronic kidney disease, wounds to the lower back and pelvis, and paraplegia. The resident’s MDS indicated moderate cognitive impairment, an indwelling catheter, and an ostomy. Review of physician orders from July through September 2025 showed no orders for care and services related to either the suprapubic catheter or the colostomy. The resident’s care plan included entries for the suprapubic catheter and colostomy, such as monitoring for infection, checking tubing for kinks, assisting with ostomy care as needed, and obtaining supplies, but the ADON stated the information was not comprehensive. During interview, the resident said he/she managed the urinary drainage bag and colostomy independently, brought supplies from home, and had not needed facility replacement supplies. The ADON stated there should have been orders for colostomy care, including cleansing and wafer changes, and for suprapubic catheter care, including cleaning and dressing changes, but none were found in the chart. The DON stated the facility did not have a policy or protocol for suprapubic catheters or ostomies.
Smoking supervision and assessment failures
Penalty
Summary
The facility failed to provide an environment free from accident hazards and failed to implement its smoking policy for two residents who smoked. The facility policy required residents to be evaluated on admission or when they chose to smoke to determine their ability to smoke safely, that smoking concerns be noted in the care plan, that supervised smokers be monitored by staff or a designee during smoking times, and that residents not keep lighters with them. One resident was admitted in July 2025 with diagnoses including type 2 diabetes, bilateral lower-extremity amputations, chronic kidney disease, and wounds to the lower back and pelvis. A smoking evaluation dated 7/22/25 stated the resident was safe to smoke with supervision and could light a cigarette with staff supervision, and social service documentation identified the resident as a current smoker. However, the resident's care plans did not include a smoking care plan reflecting current smoking status. During observation on 9/8/25, six residents were waiting in the hallway for the 11:00 A.M. smoke time without staff present, then exited through a locked door using a keypad code. There was no staff supervision in the smoking area when the resident was observed with a lit cigarette, another resident asked that resident for a lighter, and a lighter was seen inside another resident's cigarette pack. A CNA did not enter the smoking area until several minutes later. Another resident, admitted in September 2024 with paraplegia and a C5 spinal cord injury, had a smoking evaluation on 3/14/25 indicating the resident did not desire to smoke, but a later evaluation on 9/3/25 indicated the resident was independent with smoking, with no additional smoking evaluations between those dates. The resident was not listed as a smoker on the facility's smoking list, yet told the surveyor that smoking had resumed a few weeks earlier and was observed smoking in the courtyard. An AA stated the resident had resumed smoking about a month earlier. The DON stated a smoking assessment should be completed as soon as a resident indicates a desire to smoke and agreed the assessment should have been completed before the resident resumed smoking to ensure safety while smoking.
Delayed Review of Pharmacist Medication Regimen Recommendations
Penalty
Summary
The facility failed to ensure that Consulting Pharmacist Medication Regimen Reviews (MRRs) were reviewed by the attending physician in a timely manner and either implemented or declined for three residents. Resident #9, admitted with diagnoses including congestive heart failure, chronic kidney disease, and an unspecified mood disorder, had MRRs dated 2/26/25, 3/19/25, and 5/15/25 that recommended clarifying the type of pain for PRN acetaminophen and oxycodone use. The 2/26/25 and 3/19/25 MRRs showed no physician response or signature, and the 5/15/25 MRR showed the recommendation was addressed but remained unsigned by the physician. Resident #31, admitted with recurrent depressive disorder, early onset Alzheimer's disease, delusion disorder, and anxiety disorder, had a 5/15/25 MRR recommending follow-up with the primary MD regarding a gradual dose reduction of Risperdal after behavioral health recommended reducing the dose. The behavioral health note also recommended a GDR and monitoring for behavior changes, but there was no documentation that the physician reviewed or declined the MRR in May 2025, and the recommendation was not implemented until 7/29/25. Resident #8, admitted with Parkinson's disease and bipolar disorder, had consultant pharmacist recommendations dated 3/19/24 and 4/24/25 to review and decrease Eliquis from 5 mg twice daily to 2.5 mg twice daily; both response sections were blank, although the April 2025 physician orders later showed Eliquis 5 mg twice daily discontinued and Eliquis 2.5 mg twice daily started on 4/30/25. The DON stated there was no evidence the consultant pharmacist recommendation forms were reviewed with the provider.
Incomplete Nutritional Supplement Orders and MAR Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not ensuring that physician orders for nutritional supplements included the amount to be administered. Review of the facility’s Nutrition policy stated that nutritional supplements are used to complement a resident’s dietary needs and that nutrition interventions are evaluated through ongoing monitoring by the interdisciplinary team. In the sample of 26 residents, two residents had supplement orders that did not specify the amount to be given, and the corresponding MARs also did not document the amount to be administered. Resident #8 was admitted with diagnoses including Parkinson’s Disease and Bipolar Disorder, and the MDS indicated significant weight loss and no prescribed weight loss regimen. The September 2025 physician order for a House supplement once daily did not include an amount, and the MAR only provided a place to document the percentage accepted. Resident #11 was admitted with diagnoses including Chronic Lymphocytic Leukemia and Heart Failure. The September 2025 physician order for a House supplement twice daily also lacked an amount, and the MAR did not show the amount to be given or the amount accepted. Nurse #4 and the DON both stated that supplement orders should include the amount to be given, and the DON stated that without that information there was no way to know how much supplement was consumed based on the percent accepted documentation.
Hospice Documentation Not Maintained or Readily Available
Penalty
Summary
The facility failed to maintain a communication process that included keeping Hospice documentation readily accessible to staff and providers for one resident receiving Hospice services. Resident #3, who was admitted to the facility in July 2017 with diagnoses including End Stage Huntington's Disease, vascular Dementia, and Dysphagia, signed on with Hospice services on 8/5/25. Review of the resident's medical record showed only a limited set of Hospice documents were readily available, including the Hospice admission agreement and informed consent, the certification of terminal illness, the Hospice plan of care, and one note from the Hospice spiritual counselor. During interviews, the ADON said she believed each Hospice resident should have a Hospice binder but was unsure where the binders were stored. A nurse stated each Hospice resident should have a separate binder to keep all Hospice documentation accessible, but was unsure whether Resident #3 had one. The Hospice clinical supervisor said Hospice staff provided handwritten or printed notes to facility nurses at each visit and expected the facility to maintain those notes in the resident's medical record. When the ADON later provided a packet of Hospice documentation, it included multiple Hospice nurses' progress notes from 8/5/25 through 9/2/25 that had not been maintained in the facility and had to be faxed after the surveyor asked. The ADON and DON also stated they were unsure who served as the liaison with Hospice, and the DON said she was unaware that Resident #3 did not have a Hospice binder and that the Hospice documentation was not readily available in the facility.
Failure to Hold Required Quarterly QAPI Meeting
Penalty
Summary
The facility failed to ensure that at least quarterly QAPI meetings were held during one of the four quarters reviewed. Record review of the facility’s last four quarter QAPI meeting attendance sheets showed that a quarterly meeting was scheduled for October 2024, but the meeting was not held. During an interview on 9/10/25 at 10:46 A.M., the Administrator stated that QAPI meetings are required to be held at least quarterly and confirmed that the facility did not hold the quarterly QAPI meeting in October 2024 as required.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure antibiotic use was monitored for one resident who was receiving Nitrofurantoin Macrocrystals 50 mg at bedtime for prophylactic treatment of recurrent UTI. The resident was admitted with diagnoses including PVD, adjustment disorder, and Parkinson's disease. Review of the resident's hospital discharge summary showed no diagnosis of UTI, no documented history of UTI, and no recommendation to start a prophylactic antibiotic for recurrent UTI. The resident's physician progress notes dated 1/17/25 and 1/19/25 documented urge incontinence of urine but did not explain why Nitrofurantoin Macrocrystals was started for prophylactic treatment of recurrent UTI. The facility's Antibiotic Stewardship Program policy stated that clinical infections treated with antibiotics would be reviewed by the Infection Preventionist or designee, antibiotic utilization would be reviewed as part of the stewardship program, and residents' antibiotic regimens would be documented on the facility-approved antibiotic surveillance tracking form. However, the Infection Preventionist line listings from February 2025 through August 2025 did not show that the resident's Nitrofurantoin use was being monitored or reviewed. During interviews, the Infection Preventionist stated she was unsure of the facility policy for tracking prophylactic antibiotic use, expected residents on antibiotics to be on the line listing, and acknowledged she was not tracking prophylactic antibiotic use in the facility. She also stated she could not find documentation supporting a history of recurrent UTIs or why the prophylactic Nitrofurantoin had been started.
Failure to Offer and Document COVID-19 Vaccine Consent
Penalty
Summary
The facility failed to ensure that one resident, who was admitted in January 2025 and was over age 65, was offered or able to decline the COVID-19 vaccine when he/she was not up to date with vaccination. Record review showed the resident’s MDS assessment indicated COVID-19 vaccination status was not up to date, and the immunization record showed the last COVID-19 vaccine was received in 2021. The immunization consent form was blank, with no indication that the vaccine was offered or declined, even though physician orders later included that the resident may have the COVID-19 vaccine. During interviews, nursing staff stated that vaccine consents or declinations were to be obtained at admission. The surveyor and a nurse reviewed the resident’s record, and the nurse stated that because the immunization consent form was not completed and consent was not obtained, the resident would be unable to receive the updated COVID-19 vaccine. The ADON also stated that there was no immunization form obtained for the resident and that she reviewed the immunization book and found no immunization form for this resident. In a later interview, the ADON said she contacted the resident’s representative, who gave consent for the updated COVID-19 vaccine, and stated that the record contained no indication the vaccine had previously been offered or declined because the consent form was blank.
Sanitation and Safety Deficiency in Kitchenettes
Penalty
Summary
The facility failed to maintain sanitary and safe conditions in two unit kitchenettes, specifically regarding the cleanliness of toasters. On July 24, 2024, observations revealed a crumb-laden toaster in Unit Two and crumbs lining the top and inside of the toaster slots in Unit One. These conditions presented a potential fire risk and were not in accordance with professional standards for food storage, preparation, distribution, and service. Interviews conducted on July 25, 2024, with the Director of Housekeeping and the Food Service Director revealed uncertainty about which department was responsible for cleaning the toasters. The Director of Housekeeping acknowledged the potential bacteria and fire risks associated with the crumb buildup. The Regional Nurse indicated that kitchenettes are cleaned twice monthly and as needed, suggesting that kitchen staff should maintain the toasters during restocking or fridge temperature checks. However, the lack of clarity in responsibility led to the observed deficiencies.
Failure to Maintain Clean Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of its units, specifically in a resident's room. Observations made by the surveyor on multiple occasions revealed multiple brown, dried drip marks on the wall and windowsill directly to the right of the resident's bed. These marks were visible to the resident, who was observed lying in bed facing the wall with the marks. The facility's cleaning policies, including the Complete Room Cleaning list and the Daily Patient Room Cleaning guidelines, require walls to be wiped as needed and vertical surfaces to be spot cleaned with a cloth and disinfectant. Despite these policies, the room in question was not adequately cleaned, as evidenced by the persistent presence of the drip marks over several days. The Director of Housekeeping confirmed that resident rooms are cleaned daily and deep cleaned monthly, and acknowledged that the room was scheduled for a deep clean prior to the surveyor's observations. The Director also stated that such drippings should have been addressed during both daily and deep cleaning routines, indicating a failure to adhere to the facility's cleaning protocols.
Failure to Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I Screening was completed prior to the admission of a resident diagnosed with serious mental illness (SMI). Specifically, the resident was admitted with diagnoses of Post Traumatic Stress Disorder (PTSD), Major Depressive Disorder, and Anxiety Disorder, but the Level I Screening was conducted nine days after admission. Additionally, the screening did not include the resident's new diagnosis of Borderline Personality Disorder, which was identified after admission. The Social Worker responsible for completing the Preadmission Screenings was unavailable at the time of the resident's admission, and no other staff member was trained to perform this task. Consequently, the necessary screenings were not completed as required. The Social Worker was also unaware of the resident's PTSD diagnosis and the subsequent diagnosis of Borderline Personality Disorder, which would have necessitated a Post Admission Level I Screening and a Resident Review. This lack of awareness and communication among staff led to a delay in the evaluation and determination of appropriate care and services for the resident.
Failure to Monitor and Document Wound Dressing
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice concerning the application and monitoring of a wound dressing for a resident. The staff did not accurately assess the resident's skin, obtain a physician's order for a dressing applied to the resident's left elbow, or provide ongoing assessment of the area. This resulted in the dressing not being changed in a timely manner, putting the resident at risk for worsening wound status and infection. The resident was admitted with a diagnosis of a displaced intertrochanteric fracture of the right femur and had a care plan that included weekly skin condition checks and the application of barrier cream to certain areas. Observations revealed that a foam dressing applied to the resident's left elbow was not documented in the physician's orders or the treatment administration record. The dressing, dated ten days prior, was observed to be intact but later found to be lifted at the edges with dry tan drainage. Interviews with the nurse who applied the dressing and the infection preventionist/unit manager indicated a lack of awareness and documentation regarding the dressing. The facility's protocol for weekly full-body skin observations was not followed, as the dressing was not identified in the non-pressure ulcer evaluation.
Incomplete Discharge Planning and Communication
Penalty
Summary
The facility failed to ensure a comprehensive discharge process for a resident, leading to a deficiency in the discharge summary and communication with follow-up care providers. The resident, who was moderately cognitively impaired and had been admitted with Parkinson's Disease and a femur fracture, expressed uncertainty about the discharge plan and desired a specific Visiting Nurse Agency (VNA) for post-discharge care. However, there was no documented discussion or arrangement for the resident's follow-up care, and the discharge summary was incomplete. The discharge planning process was inadequately executed, as evidenced by the lack of a completed discharge summary from the Therapy and Social Work departments. Although the nursing department completed their portion of the Discharge/Transfer Evaluation, the necessary information regarding ongoing community services, such as VNA services, was not included. The Social Worker and Director of Rehabilitation were unaware of who made the referral to the VNA, and the VNA contact confirmed that no referral had been made until after the resident's discharge. Interviews with facility staff revealed a lack of coordination and communication regarding the discharge process. The Social Worker acknowledged that the Discharge/Transfer Evaluation should have been completed before the resident's discharge, and the Director of Rehabilitation admitted that the Therapy department failed to complete their portion of the evaluation. The Regional Nurse confirmed that the Social Work Department was responsible for making VNA referrals, which should have been done prior to discharge, but this was not completed, resulting in a delay in the resident receiving necessary post-discharge services.
Failure to Develop Trauma Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive Trauma Informed Care Plan for a resident diagnosed with PTSD. The resident was admitted in May 2024, and the Social Services Evaluation conducted on 5/15/24 indicated that the resident had past experiences that were emotionally, spiritually, physically, or behaviorally upsetting. This evaluation recommended the creation of a Care Plan related to Trauma Informed Care. However, a review of the resident's Comprehensive Care Plan revealed no documentation of such a plan being developed. During an interview, the Social Worker acknowledged that a Trauma Informed Care Plan should have been created for the resident but was not.
Incomplete CNA Documentation for Meal Intake
Penalty
Summary
The facility failed to ensure complete and accurate documentation by a Certified Nurses Aide (CNA) for a resident with a history of significant weight loss and increased risk for nutritional decline. The resident, admitted in May 2022, had diagnoses of muscle wasting, atrophy, and chronic pain. A Dietician's Progress Note from June 2024 identified a significant weight loss of 7.8% over three months. The care plan, initiated in May 2022 and revised in May 2024, required monitoring and recording of meal intake every meal. However, the CNA documentation for June and July 2024 showed incomplete records, with only 58 of 90 meals in June and 36 of 73 meals in July having documented meal intake percentages. Interviews with facility staff revealed that meal intake documentation was expected to be recorded each shift. The Dietician noted that incomplete documentation hindered her ability to make necessary dietary adjustments, as she often had to seek additional information verbally from staff. The Regional Nurse confirmed that CNAs were not documenting meal intakes every shift as required, which was evident upon reviewing the resident's meal intake records for June and July 2024.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to a resident's guardian. This notice is crucial for informing the resident or their guardian about the end of Medicare Part A coverage and any potential financial liabilities for continued services. The deficiency involved a resident who was admitted in August 2023, and the facility did not successfully contact the guardian to inform them of the last covered day of Medicare Part A services, which was set for June 13, 2024. Attempts to contact the guardian on June 11, 2024, were unsuccessful, and the facility claimed to have sent a certified letter, but there was no evidence of this action. During an interview, the facility's administrator acknowledged the failure to provide the necessary documentation to the guardian. The administrator noted that the process should have included sending a certified letter and maintaining the return receipt for records, but no such receipt or evidence of mailing was found. This oversight left the resident's guardian uninformed about the termination of Medicare coverage and the potential financial responsibility for continued skilled services.
Failure to Provide Transfer and Discharge Notice
Penalty
Summary
The facility failed to provide a written Notice of Transfer and Discharge to a resident and their representative at the time of discharge. Specifically, the staff did not issue a Notice of Intent to Transfer and Discharge when the resident was transferred from the facility to the hospital. The resident was admitted to the facility in July 2023 and was transferred to the hospital on May 12, 2024. A review of the resident's medical record showed no documentation of the required notice being provided at the time of discharge or shortly thereafter. Interviews with facility staff revealed a lack of clarity and responsibility regarding the issuance of the notice. The Social Worker stated that she does not provide the notice when a resident is transferred to the hospital, indicating that it was the nursing staff's responsibility. The Infection Preventionist, who also served as the Unit Manager, confirmed that neither the resident nor their representative received the notice and acknowledged that no education had been provided to the nursing staff about this requirement.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kimball Farms Nursing Care Center | 2.7 mi | ★★★★★ | 3 | 0 |
| Mount Carmel Care Center | 4.9 mi | ★★★★★ | 0 | 0 |
| Springside Rehabilitation And Skilled Care Center | 7.9 mi | ★★★★★ | 2 | 0 |
| Berkshire Place | 8 mi | ★★★★★ | 2 | 0 |
| Hillcrest Commons Nursing & Rehabilitation Center | 9.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.