Lee Health And Rehab Center

In the surveyor’s words

From the most serious findings on record at Lee Health And Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF580Apr 8, 2026

  Based on staff interview, clinical record review and facility document review the facility staff failed to notify the resident's representative of a change in condition requiring medical intervention for 1 of 3 residents, Resident #1.The findings included:Resident #1's clinical record listed diagnoses which included but not limited to metabolic encephalopathy, aphasia and dysphagia.Resident #1's face sheet did not list an authorized representative/responsible party but did list four emergency contacts.Resident #1's most recent minimum data set with an assessment reference date of 11/03/25 assigned the resident brief interview for mental status score of 3 out of 15 in section C, cognitive patterns. This indicates that the resident was severely cognitively impaired. […]

• No harm, potential for more than minimal, isolatedF684Mar 6, 2025

  Based on staff interview and clinical record review, the facility staff failed to ensure residents receive treatment and care in accordance with the comprehensive person-centered care plan and medical provider orders for 1 of 24 sampled residents, Resident #61. The findings included: For Resident #61, the facility staff failed to follow the medical provider's order for the administration of the narcotic pain medication Oxycodone. Resident #61's diagnosis list indicated diagnoses, which included, but not limited to Displaced Intertrochanteric Fracture of the Left Femur, End Stage Renal Disease, and Chronic Obstructive Pulmonary Disease. […]

• No harm, potential for more than minimal, isolatedF812Mar 6, 2025

  Based on observation, staff interview and facility document review, the facility staff failed to store food in accordance with professional standards for food service safety in one of 3 resident refrigerators. The findings included: On 3/6/25 at 8:26 AM this surveyor checked the resident refrigerator on one of 3 units. The thermometer read 40 degrees. This surveyor noted an 8-ounce carton of Very Vanilla Soy Silk beverage with an expiration date of 12/19/24. This surveyor took the beverage to the Registered Dietician (RD) who stated, This isn't something we provide. It probably belonged to a patient who has been discharged . This surveyor pointed out that there was no name on the carton. The RD did verify the date and that the item was expired. […]

• No harm, potential for more than minimal, isolatedF684Jun 28, 2023

  Based on interviews, clinical record review, and facility document review, the facility staff failed to provide medication in accordance with provider orders for 1 of 6 residents in the survey sample, Resident #3. The findings were: For Resident #3, the facility staff failed to administer the antibiotic as ordered by the provider. Resident #3's admission record listed diagnoses to include but not limited to, monoplegia of lower limb following cerebrovascular disease affecting right dominant side, type 2 diabetes mellitus with diabetic neuropathy, mood (affective) disorder, anxiety disorder, pneumonia, and urinary tract infection. […]

• No harm, potential for more than minimal, isolatedF842Jun 2, 2022

  Based on staff interview and clinical record review the facility staff failed to maintain a complete and accurate clinical record for 2 of 21 residents, Residents #104 and #255. 1. For Resident #104, the facility staff failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 2. For Resident #255, the facility staff failed to accurately complete a Durable Do Not Resuscitate (DDNR) order form. The findings included: 1. Section C (cognitive patterns) of Resident #104's significant change minimum data set (MDS) assessment with an assessment reference date (ARD) of 05/19/22 included a brief interview for mental status summary score (BIMS) of 9 out of a possible 15 points. Section H (bladder and bowel) was coded to indicate the resident had a foley catheter in place. […]