Lee Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880Jan 11, 2021

  Based on observation, interview and record review the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) regarding isolation of COVID-19 residents related to cohorting of COVID-19 residents, ensuring signage for the specific use of PPE (personal protective equipment) was posted, and ensuring staff wore the appropriate PPE to prevent the spread of COVID-19. These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. […]

• Actual harm, patternF686Mar 24, 2022

  Based on observation, interview, and record review, the facility failed to follow their wound care protocols to prevent the development and worsening of pressure ulcers; and failed to consistently implement interventions, monitoring, and bed-linen management care to prevent further worsening and/or development of new and existing pressure ulcers for 5 (R72, R111, R153, R167, and R148) of 12 residents reviewed for pressure sores in the sample. These failures resulted in all 5 residents sustaining avoidable stage 3 pressure ulcers, stage 4 pressure ulcers, unstageable pressure ulcers and worsening pressure ulcers. […]

• Actual harm, isolatedF689Jul 17, 2026

  Based on interview and record review, the facility failed to provide appropriate transfer for a resident who is Dependent for transfers requiring a mechanical lift transfer with 2 persons transfer assist due to being non-ambulatory. This deficiency affects one (R210) of three residents reviewed for accidents and incidents. This failure resulted in R210 to have a right lower leg laceration requiring 12 stiches. Findings include:R210 is a [AGE] year-old admitted on [DATE] to the facility with the following diagnosis in part but not limited to Alzheimer's disease with late onset, Vascular Dementia unspecified, unsteadiness on feet, other abnormalities of gait and mobility, weakness, presence of right artificial knee joint.Facility Reported Incident dated 6/27/26 documents at approximately… […]

• Actual harm, isolatedF686Apr 18, 2025

  Based on interviews and records reviewed the facility failed to complete a wound assessment and document treatment and findings of the assessment of one resident (R91) who developed a reddened area on her left and right buttock, and failed to ensure there were effective interventions to prevent further deterioration. This failure affected one of five of 5 (R91) reviewed for pressure ulcers in a sample of 36. This failure resulted in R91 developing an unstageable pressure ulcer that required debridement. The findings include: R9's diagnosis include but are not limited to Alzheimer's Disease, Parkinson's Disease, Diabetes, Retention of Urine, Vascular Dementia, Cognitive Communication Deficit, and Need for Assistance with Personal Care. […]

• Actual harm, isolatedF689Apr 18, 2025

  Based on interviews and records reviewed the facility failed to follow their practice and provide 2 person assist with bed repositioning of a dependent resident. This failure affects one of three residents (R91) reviewed for falls. This failure resulted in R91 falling out of bed when staff turned her and sustained head injury requiring 1 staple to the back of her head. The findings include: R91 is nonverbal and diagnosis include but are not limited to Alzheimer's Disease, Parkinson's Disease, Diabetes, Retention of Urine, Vascular Dementia, Cognitive Communication Deficit, and Need for Assistance with Personal Care. On 4/17/25 at 12:33PM V7, Assistant Director of Nursing, said on 4/5/25 around 6:00am R91 had a fall. V7 said I interviewed staff on Monday, including V20, CNA. […]