Marjorie P Lee Retirement Community

In the surveyor’s words

From the most serious findings on record at Marjorie P Lee Retirement Community, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 4, 2025

  Based on medical record review, review of the facility incident report, review of Root Cause Analysis report, hospital record review, resident, visitor, and staff interviews, review of personnel file, and policy review, the facility failed to ensure a resident was positioned safely during personal care. This resulted in Actual Harm to Resident #10 on 02/16/25 when Certified Nursing Assistant (CNA) #150 did not position Resident #10 correctly while providing personal care in bed and did not call for assistance prior to moving the bed when the resident was in a compromised position resulting in Resident #10 sustaining a left hip fracture, a small scalp laceration to the front top of her head, an abrasion to the right forearm, and a bruise with eye bleed to the left eye. […]

• No harm, potential for more than minimal, widespreadF812Jan 29, 2026

  Based on observation, record review, interview, and review of facility policy, the facility failed to store food items in a sanitary manner, failed to ensure proper hair covering was maintained in the kitchen, and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all 71 residents who were identified as receiving food from the kitchen. Facility census was 71.Findings Include:Observation of walk-in freezer in the main kitchen area on 01/27/26 at 9:23 A.M. revealed open bags of plant-based meatballs and hamburger patties that were in unsealed bags, open to air and undated. These findings were confirmed in a concurrent interview with the Dining Service Director (DSD) #310. […]

• No harm, potential for more than minimal, isolatedF803Jan 29, 2026

  Based on observation, record review, staff interview, and facility policy review, the facility failed to prepare pureed foods to ensure nutritive value and palatability were maintained. This affected one resident, (#13) who was identified as the only resident in the facility who require a pureed diet. The facility census was 71.Findings Include:Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, malnutrition, urinary retention, anxiety disorder, depression, chronic constipation, atherosclerotic heart disease and osteoporosis.Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired, and was dependent for all… […]

• No harm, potential for more than minimal, isolatedF880Jan 29, 2026

  Based on observation, interview and record review, the facility failed to ensure enhanced barrier precautions were implemented for one, Resident #13. This affected one of one resident reviewed for enhanced barrier precautions. Facility census was 71. Findings Include:Review of medical record for Resident #13 revealed an admission date of 02/26/21. Diagnoses included dementia with behavioral disturbance, malnutrition, urinary retention, anxiety disorder, depression, chronic constipation, atherosclerotic heart disease and osteoporosis.Resident #13's Minimum Data Set (MDS) assessment dated [DATE] revealed resident was severely cognitively impaired, was dependent for all activities of daily living including bed mobility and transfers. […]