Lee County Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Lee County Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Apr 18, 2024

  Based on staff interviews and record review, the facility failed to ensure that medications were administered as care planned to ensure critical laboratory results remained within a therapeutic range for one of nine residents (R) (R1) sampled. On 4/16/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing, and nurse consultant via phone were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 10:15 am. The noncompliance related to the IJ was identified to have existed on 12/30/2023. An Acceptable IJ Removal Plan was received on 4/17/2024. […]

• Immediate jeopardy, isolatedF760Apr 18, 2024

  Based on staff interviews, record reviews, and a review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy, the facility failed to ensure that one of nine sampled residents (R) (R1) obtained medications timely, administered as ordered, and medication trough levels were maintained within a therapeutic range for R1. On 4/16/2024 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing, and nurse consultant via phone were informed of the Immediate Jeopardy (IJ) on 4/16/2024 at 10:15 am. […]

• No harm, potential for more than minimal, patternF759Apr 18, 2024

  Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration-General, the facility failed to ensure the medication error rate was less than 5%. A total of 35 opportunities were observed with four errors for three residents (R) (R2, R7, and R8) resulting in an error rate of 11.4%. This failure had the potential to result in medication not being given in accordance with the physician's orders and had the potential to adversely affect R2, R7 and R8's clinical condition. Findings include: Review of the facility policy titled, Medication Administration-General, dated 2024. The policy guidelines included that medications are administered in accordance with a valid prescriber order. […]

• No harm, potential for more than minimal, isolatedF656Mar 12, 2023

  Based on record review, staff interviews, and review of facility policy titled, 'Skilled Nursing Services-Patient's Plan of Care', the facility failed to develop and implement a person-centered care plan for two of 27 residents (R) (R#9 and R#40) related to restorative nursing services. Specifically, the facility failed to implement restorative services for R#9 as indicated by plan of care, and the facility also failed to ensure that a care plan was developed to include restorative services for R#40. Findings include: Review of facility policy titled; 'Skilled Nursing Services-Patient's Plan of Care' last reviewed 12/30/2022 revealed: 'Intent-To promote person-centered patient care through a comprehensive care plan. […]

• No harm, potential for more than minimal, isolatedF657Mar 12, 2023

  Based on record review, staff interview, and review of facility policies titled, 'Skilled Nursing Services-Patient's Plan Care' and 'Skilled Nursing Services-Fall Management', the facility failed to ensure the care plan for one of four residents (R) (R#37) was revised after a fall with major injury. Findings include: Review of facility policy 'Skilled Nursing Services-Patient's Plan of Care' last reviewed 12/30/2022 revealed: 'Procedure-The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. […]