Letcher Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF602Apr 5, 2024

  Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents were free from misappropriation of property. Controlled substances/medications were misappropriated without authorization from eight (Resident (R) 4, R10, R11, R13, R45, R78, R86 and R90) of 89 sampled residents. The findings include: Review of the facility's undated policy titled, Resident Rights, revealed each resident had the right to receive treatment and supports for daily living safely. […]

• No harm, potential for more than minimal, isolatedF550Apr 16, 2026

  Based on observation, interview, record review and review of facility policy, the facility failed to ensure the resident could exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility for 3 of 19 sampled residents who required supervised smoking, Resident (R)22, R75, and R90.The findings include: Review of the facility's policy titled, Resident Rights, dated 08/13/2024, revealed, the resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. […]

• No harm, potential for more than minimal, isolatedF583Apr 16, 2026

  Based on observation, interview, record review, review of the facility's policy, and the facility's Employee Confidentiality and Non-Disclosure Agreement, the facility failed to ensure confidentiality of the Electronic Medical Record (EMR) for 1 of 38 sampled residents, Resident (R)93. Observation on 04/15/2026 at 11:28 AM, on the F Hall, revealed staff left R93's computer display screen open on top of the unattended Medication cart, allowing the resident's personal and medical information to be visible to others on the unit.The findings include: Review of the facility's Employee Confidentiality and Non-Disclosure Agreement, revised April 2003, revealed employees should not leave your computer terminal or workstation unattended without logging off or using your system's screen saver… […]

• No harm, potential for more than minimal, isolatedF755Apr 16, 2026

  Based on interview, record review, and review of facility policy, the facility failed to provide medications in a timely manner to treat a Urinary Tract Infection (UTI) for 1of 38 sampled residents, Resident (R)117. R117 developed a UTI and Fosfomycin 3 grams as a single-dose treatment (antibiotic) was ordered on 11/11/2026 at 11:28 AM. However, the medication was not administered until 11/15/2025 at 4:23 PM, 4 days later. The resident experienced pain and discomfort.The findings include: Review of the facility's policy titled, Medication ordering and receiving from Pharmacy, dated November 2021, revealed the Administrator, Director of Nursing, and dispensing pharmacy established a daily delivery and pick-up schedule for medication orders. […]

• No harm, potential for more than minimal, isolatedF761Apr 16, 2026

  Based on observation, interview, and review of the facility's policy, the facility failed to ensure medications which had been opened were properly labeled with the open and expiration dates for 1 of 8 medication carts.The findings include: Review of the facility's policy titled, Medication Storage in the Facility, dated November 2021, revealed the policy set forth included expiration dating (beyond-use date). Additional review of the policy revealed when the original seal of a manufacturer's container or vial was initially broken, the container or vial would be dated, if applicable for medications requiring a shortened expiration date. The nurse shall place a date opened sticker on the medication and enter the date opened and new date of expiration, if applicable. […]