Lea Hill Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Lea Hill Rehabilitation and Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 9, 2021

  Based on observation, interview and record review, the facility failed to ensure 3 (Residents 21, 10 & 11) of 3 residents received the therapeutic altered liquids they were assessed to require. These failures increased the likelihood of choking, aspiration (breathing fluid or food into the lungs), pneumonia and death for these residents and constituted an immediate jeopardy. On 12/01/2021 an IJ was identified and the Provider was informed. On 12/01/2021, the facility removed the immediacy by ensuring residents were correctly assessed for the proper textured liquids, staff were trained to provide the correct textured liquids, and residents were provided with the correct textured liquids. […]

• Actual harm, isolatedF686Apr 3, 2023

  Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 23) reviewed for pressure ulcers (PU) received physician ordered wound care, and a recommended air mattress on a timely basis to prevent skin breakdown and the development and worsening of PUs. These failures resulted in harm to Resident 23 due to worsening of PU on the heels and increased risk for severe infection and further deterioration of skin integrity. Findings included . According to the 10/2022 facility policy Pressure Injury Risk Assessment residents who were determined at risk for developing pressure ulcers would have interventions documented in the Care Plan (CP) based on specific individualized factors identified in the risk assessment. […]

• No harm, potential for more than minimal, widespreadF623Jul 2, 2024

  Based on interview and record review, the facility failed to implement a system to ensure residents received required written notices at the time of transfer/discharge, or as soon as practicable for 2 (Residents 21 & 29) of 2 residents reviewed for hospitalization s. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . […]

• No harm, potential for more than minimal, widespreadF812Jul 2, 2024

  Based on observation and interview, the facility failed to ensure resident meals were prepared in accordance with professional standards of food safety for 2 of 2 facility kitchens. The failure to ensure surface sanitizer solutions were maintained at effective concentrations, food was stored in a manner to preserve its quality, and food preparation areas were free from potential contaminants, placed residents at risk for food contamination, food borne illnesses, and spoiled food. Findings included . Observation on 06/26/2024 at 9:12 AM showed dietary staff cleaning up after breakfast service. At that time Staff P (Dining Services Director) reached for a test strip to verify the kitchen's surface sanitizer was at the correct consistency (100-440 PPM - Parts Per Million). […]

• No harm, potential for more than minimal, widespreadF812Apr 3, 2023

  Based on observation and interview the facility failed to ensure expired foods were identified and discarded, did not ensure equipment was clean and secure, and ensure staff implemented proper hand hygiene practice. These failures placed residents at risk for consuming expired/spoiled foods, potential exposure to food borne illness, and safety hazards placing residents at risk for harm. Findings included . Expired food An observation on [DATE] at 8:34 AM found the following foods identified as expired inside facility kitchen refrigerators; Cooked bacon, pork ham lunch meat, pickles, a pitcher of tomato juice, a pitcher of skim milk, a pitcher of orange juice, and three pitchers of instant tea. […]