Lee Healthcare

In the surveyor’s words

From the most serious findings on record at Lee Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF684Sep 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure that professional standards of practice were implemented relative to skin and wound care for one Resident (#19) of four applicable residents reviewed for wound care, out of a total sample of 26 residents. Specifically, for Resident #19, the facility failed to: -appropriately assess and implement skin care and diabetic foot care for the Resident with a history of Diabetes, Peripheral Vascular Disease and a right below knee amputation (BKA), resulting in left toe wounds not being identified and treated timely. -submit a referral to the Wound Care Provider timely for on-going wound care when diabetic wounds were identified on the toes of the Resident's left foot. […]

• No harm, potential for more than minimal, widespreadF812Jul 25, 2024

  Based on observation and interview, the facility failed to maintain sanitary and safe conditions for two unit kitchenettes (Unit One and Unit Two) out of two unit kitchenettes. Specifically, the facility failed to maintain clean and sanitary conditions for the toasters in both Unit One and Unit Two kitchenettes that presented a fire risk. Findings include: On 7/24/24 at 2:38 P.M., the survey observed the following on the Unit Two Kitchenette: -A crumb laden toaster. On 7/24/24 at 3:00 P.M., the surveyor observed the following in the Unit One kitchenette: -Crumbs lining the top of each toaster slot. -Larger crumbs inside of the toaster slot. […]

• No harm, potential for more than minimal, patternF726Sep 10, 2025

  Based on interview and record review, the facility failed to ensure three Nurses (Nurse #2, #3 and #4), of five Nurses reviewed, had been evaluated upon hire and/or annually to ensure skills and competencies were met relative to wound care.Specifically, for one Resident (#19) who had diabetic wounds, the facility failed to ensure Nurses #2, #3, and #4, who provided care to Resident #19, were evaluated upon hire and/or annually to ensure they had the skill sets and competencies when providing wound care. […]

• No harm, potential for more than minimal, patternF730Sep 10, 2025

  Based on interview and record review, the facility failed to complete a performance review of every nurse aide at least once every 12 months, for five Certified Nurse Aide (CNA #1, #2, #4, #5, and #6), out of five total records sampled. Specifically, the facility failed to ensure annual performance reviews were completed every 12 months for CNAs #1, #2, #4, #5, and #6. Findings include: Review of the facility provided CNA Active Employee Listing, undated, indicated the following: -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. -CNA #6 was hired 2/5/24. During an interview on 9/9/25 at 2:51 P.M., the Director of Nursing (DON) said CNA performance reviews should be completed annually with all CNA's who worked in the facility. […]

• No harm, potential for more than minimal, patternF695May 9, 2023

  Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice and the comprehensive care plan for five Residents (#3, #39, #42, #28, #103) out of six applicable residents with respiratory care needs, out of a total sample of 15 residents and one closed record for Resident (#51) out of a total sample of two closed records. Specifically, the facility failed to ensure its staff: -posted signage relative to Oxygen (O2) use, -delivered O2 at the prescribed flow rate, -labeled, dated, and stored oxygen tubing and respiratory equipment properly between use, -and had comprehensive orders in place for the use and care of Continuous Positive Airway Pressure machines (CPAP- machine used to treat sleep apnea… […]