A list of the most recent deficiencies for Lee Healthcare. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-05-09 | 2023-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-06 | 2023-06-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-09 | 2023-06-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-09 | 2023-06-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-05-09 | 2023-06-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-09 | 2023-06-06 | N |
| Post nurse staffing information every day. | Health | 2023-05-09 | 2023-06-06 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-05-09 | 2023-06-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-05-09 | 2023-06-06 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-16 | 2023-06-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-11 | 2023-04-28 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-11 | 2023-04-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-10-12 | 2021-11-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-12 | 2021-11-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-10-12 | 2021-11-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-12 | 2021-11-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-12 | 2021-11-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-12 | 2021-11-12 | N |
| Provide appropriate foot care. | Health | 2021-10-12 | 2021-11-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-12 | 2021-11-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-12 | 2021-11-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-10-12 | 2021-11-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-12 | 2021-11-12 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-10-12 | 2021-11-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-12 | 2021-11-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-12 | 2021-11-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-11-14 | 2019-11-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-11 | 2019-10-25 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-09-11 | 2019-10-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-11 | 2019-10-25 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-09-11 | 2019-10-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-09-11 | 2019-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-11 | 2019-10-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-11 | 2019-10-25 | N |
| Provide activities to meet all resident's needs. | Health | 2019-09-11 | 2019-10-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-11 | 2019-10-25 | N |
| Provide appropriate foot care. | Health | 2019-09-11 | 2019-10-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-11 | 2019-10-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-09-11 | 2019-10-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-11 | 2019-10-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-09-11 | 2019-10-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-11 | 2019-10-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-11 | 2019-10-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-09-11 | 2019-10-25 | N |
